The Psychology of Religion, Chapter 4: The Main Thesis

With these acknowledgments in mind, I still have to state my main thesis plainly: the literal supernatural claims at the core of religions are not true. Many sacred stories appear to have, at most, an idealized or embellished relationship to actual figures or events; many others are best understood as products of the same mythic and literary world as the cultures around them. 

We see recurring motifs across civilizations: flood narratives in Mesopotamian texts such as Atrahasis and Gilgamesh that strongly resemble later biblical flood storytelling; traditions of extraordinary or divinely marked birth; and narratives of divine descent, death, restoration, or return that later readers sometimes compare with resurrection themes, though the parallels are not always neat. Even the moral ideas often presented as uniquely Christian have deep pre-Christian pedigrees. The command to love one’s neighbour is already in the Hebrew Bible; versions of reciprocity appear in Confucian and Indian traditions; and the psychological logic of non-retaliation emerges in multiple moral traditions long before Christianity. Christianity did not invent moral grammar from nothing; it inherited, recombined, amplified, and ritualized themes that human cultures had been discovering for a very long time.

All religions contain stories that can have moral lessons and often reflect the history of cultural groups striving to improve justice, security, morality, happiness, and harmony in their civilizations, while reflecting on human foibles. Modern religions are not very much different from other historical mythologies, such as Greek, Roman, or Egyptian mythology: they have profoundly shaped culture, and they continue to give us interesting, thoughtful stories, but they are not generally treated as literal truths. The fact that religious narratives can be psychologically helpful, ethically suggestive, or aesthetically beautiful does not make their supernatural claims true; it makes them powerful cultural creations, which is a different category.

It is also worth noticing that while religion is ancient, many features of large-scale organized religion—public priesthoods, written canons, institutional authority, standardized doctrine, and state alignment—intensified alongside agriculture, cities, and larger political structures. In such settings, religion can function as social “glue”: a way to unify large groups, encode shared identity, and establish norms for how people should behave together in communities far larger than anything most hunter-gatherer minds evolved to manage.

Not surprisingly, many sacred texts contain themes of intergroup conflict, invasion, conquest, boundary maintenance, and rules for cooperation—stories shaped by the political pressures, environmental constraints, and moral agendas of their times, repeatedly revised and reinterpreted, and naturally inclined to aggrandize the moral standing of the home tribe. In that way, religions can function like other art forms—literature, theatre, poetry, film—sometimes illuminating human experience, sometimes acting as tools of persuasion, and sometimes sliding into outright propaganda.

People become deeply attached to religious beliefs through powerful psychological forces. Most of all, there is longstanding commitment—often beginning in childhood—bolstered by parents, friends, admired community figures, and the sheer comfort of familiarity. It is as though roots form around a belief system, growing deeper over time, intertwined with identity, memory, and the need for coherence. Weakening those roots can feel like a threat to one’s sense of self, one’s social safety, and one’s personal integrity. For many, it would also be embarrassing—or even humiliating—to admit that something they have honored for decades might be false or misguided; so the mind protects itself by doubling down on prior commitments.

We see versions of this phenomenon far beyond religion, including in medicine and science.  Many people like to imagine that scientists change their views rationally according to evidence. But even among highly educated experts, new frameworks are often resisted when they threaten status, identity, professional sunk costs, or a lifetime of being “the one who knows.” History is full of examples: the Copernican move toward a Sun-centred system; the germ theory of infectious disease; the slow acceptance of plate tectonics; the bacterial role of Helicobacter pylori in peptic ulcer disease; Boltzmann’s atomic theory and statistical mechanics; Cecilia Payne’s early demonstration that stars are composed primarily of hydrogen (and helium); and the recognition of prion diseases as a genuinely new kind of infectious process. 

In each case, the evidence did not simply land on neutral minds; it collided with human psychology—pride, fear, loyalty, identity, and the discomfort of having to revise one’s story about reality.  But unlike religion, science contains formal mechanisms for correction.  

At times, the advent or widespread adoption of a new religion has been followed by improvements in a society’s stability. But the reasons for this, as I will argue, often have less to do with the truth of any particular doctrine, or the real existence of any divinity with imagined powers, and more to do with what I would call “nonspecific factors”: the social technology of shared rituals, shared identity, shared moral language, mutual aid, and coordinated behavior—effects that can be psychologically and culturally potent even when the beliefs are false.



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The Psychology of Religion, Chapter 3: Benefits of Religion

Discussions about religion from a psychological—or more broadly scientific—point of view require great care. For most believers, faith is not just an intellectual position. It is a lived emotional landscape, developed over a lifetime. Religious beliefs are often taught in early childhood, and they can represent a fundamental bond and a shared culture with parents and ancestors, sometimes going back centuries.

Religion as Family Inheritance

Religious stories, passages from religious texts, and familiar rituals can become like a “native language,” in the sense of the fluency and familiarity people develop through repeated exposure and practice over many years. Shared religious beliefs can be a bridge to memories of parents—alongside memories of fishing together, playing baseball, going camping, playing music, or cooking together. In that sense, religion is not simply an “idea.” It is the atmosphere of the family home—a mood, a shared vocabulary, and a living link to one’s past.

Unlike hobbies, however, religion carries a far heavier weight. A parent might be mildly disappointed if a child dislikes baseball; with religion, the stakes are much higher. Parents may insist—with fear, sadness, anger, or a sense of emergency—that their children must remain within the same faith. If the children stray, guilt can be induced in ways that are far deeper than ordinary family disagreements. In extreme cases, the divergence leads to estrangement or disowning. It is hard to overstate how high the emotional cost can be, in some families, for simply asking religious questions out loud.

A huge reason why many people are religious is because the people they have loved most have been religious: parents, grandparents, mentors, teachers, community leaders, or admired public figures (for me, someone like Desmond Tutu or Martin Luther King). When these beloved figures explain their moral courage, comfort, or meaning as flowing from God, the religion becomes fused with the goodness of the person. 

Out of love and respect, many people continue the same faith—not because they have evaluated the evidence with fresh eyes, but because questioning the belief can feel like questioning the beloved person. It can feel, emotionally, like an insult to one’s parents, or a betrayal of one’s ancestors, or a rejection of one’s own story. Over time, religion can become so interwoven with identity that challenging it feels less like an intellectual inquiry and more like a renunciation of a precious part of oneself.

Religion as Neurobiological Experience

Beyond family attachment, there is the brain itself: the human mind is remarkably capable of mystical experience. Many people have had moments—alone or in groups—of awe, presence, unity, transcendence, or “spiritual certainty.” Whatever one concludes philosophically, the raw fact is that such states are part of the normal range of human experience. And they can be intensified or triggered by particular brain states: by drugs that act strongly on serotonin and dopamine systems, by sleep deprivation, by stress, and in some neurological conditions. Wilder Penfield’s neurosurgical stimulation work in the mid‑20th century, for example, illustrates how focal stimulation can produce vivid sensory phenomena and “dreamy states” that feel subjectively profound. In temporal lobe epilepsy, similarly, some people report intense subjective or spiritual states in association with seizure activity.

A point that matters here—psychiatrically—is that the brain constantly seeks to make sense of things. When something unusual happens in perception, emotion, or bodily feeling, the mind strains to explain it. Often a mystical explanation feels logical even when the actual cause is biological.  A powerful feeling state can be interpreted as “God,” “fate,” “destiny,” “the universe speaking,” or “a presence,” depending on one’s cultural vocabulary and expectations.

The same instinct often fuels belief in other mystical phenomena, such as ghosts, spirits, or psychic abilities. These beliefs can act as a lens for understanding reality, where coincidences are read as evidence of a hidden world. This can make life feel “magical” in a deeply satisfying way, offering a sense of specialness and wonder akin to the feeling one gets from a fantasy story like Lord of the Rings or Harry Potter.

Religion as Culture

The vocabulary we use to describe these states matters. Many religious phrases are woven into everyday language; other words and symbols have roots in ancient mythology. For example, our word “panic” comes from the Greek god Pan, and our month “January” is named for the Roman god Janus. Language forms a lens—deeply ingrained in the brain through memory infused with emotion—through which we describe and interpret experience; in a religious household, one naturally develops the habit of interpreting events with religious references in mind, because those are the interpretive tools one has practiced. And historically, in some homes and communities, scripture was not merely a weekly reading—it was a central text around which literacy and moral education were organized.

Religion has also served, in many families and cultures, as a framework for moral development. Lessons about how to be kind, how to deal with guilt or mistakes (“sin”), how to navigate conflict, how to be a decent citizen, how to face suffering and loss—these have often been taught through weekly sermons, study of sacred texts, and the social modeling that occurs in a community of adults trying (at least some of the time) to be better people. Daily habits—such as saying grace—can instill a rhythm of gratitude. Religious services often use architecture, music, and ritual to evoke awe and reverence. And it would be dishonest to deny the artistic beauty and power that has emerged from religious contexts: sacred music, religious painting and sculpture, the architecture and acoustics of churches, cathedrals, temples, mosques. Many of my own favorite pieces of music are deeply tied to that history.

It is no surprise, then, that for many people their happiest memories—friendship, loyalty, meaningful service, celebration, “ecstatic” spine-tingling moments of being emotionally moved—are associated with church or religious community. Many believers interpret these peak emotional states as manifestations of God. As a psychiatrist, I see no reason to treat them as anything other than natural emotional states whose interpretation is culturally shaped: in a cathedral, at a concert, at a political rally, in nature, or even at a sports event. 

This communal power is often concentrated through the figure of the minister. Some ministers are wonderful orators: gifted storytellers with compelling voices, humor, and genuine moral seriousness—sometimes with a breadth of knowledge about history and literature that makes their sermons a kind of free education in the humanities. Some of the great orators in modern history, such as Martin Luther King, were ministers. Churches have been one of the few sustained modern venues where people regularly gather to hear impassioned, ethically themed rhetoric delivered with skill and intensity. Mind you, preaching can be used for darker purposes: demagogues can weaponize charisma, spectacle, and group emotion to fuel intolerance.

Religion as Refuge

Religion can also function as refuge. Many people who feel lonely, adrift, or ungrounded are drawn to a religious or spiritual group because it offers instant community: new friendships, mentorship, comforting rituals, structure, sometimes even material support, and a ready-made language for meaning. This differs from many other community organizations because the commitment is thicker: it is not merely “we play badminton together,” but “we share a destiny that goes beyond this life.” It's a little bit like an orphan finding a home and then gratefully adopting the new family’s beliefs.

This is also part of why religious (and ideological) communities can become so resilient: they meet deep social and psychological needs. Research on radicalization and extremist commitment—work associated with researchers such as Nafees Hamid—has explored how peer influence, identity, and social exclusion can harden commitment in tightly bound groups. The point here is not to equate ordinary religious life with extremism, but to recognize a shared human vulnerability: when belonging and identity are fused to belief, questioning belief can feel like social annihilation.

Religion as Charity

It would also be unfair not to acknowledge the amount of genuine charitable work done by some churches, including some quite conservative ones. In downtown Vancouver, for example, a well-known fundamentalist church has helped provide temporary winter shelter for street-involved adults; and on a much larger scale the Salvation Army reports thousands of shelter, detox, addiction, mental-health, supportive-housing, healthcare, and corrections beds available each night across its Canadian programs, millions of meals distributed, and large numbers of street-outreach interactions plus housing and employment referrals. The financial scale is substantial as well: Statistics Canada reports that religious organizations receive billions per year in donations. 

Still, this needs to be interpreted carefully. These figures do not mean that all religious giving goes directly to the poor, and church charity can at times be paternalistic or conditional—tied to sobriety rules, doctrinal messaging, or a subtle expectation of loyalty. Nor is this benevolence unique to religion: secular charities, food banks, municipal programs, and public agencies also provide shelter, low-cost food, outreach, housing support, and addiction services. So the charitable success of churches is real, and sometimes admirable, but it demonstrates the power of organized community, volunteer labour, and pooled resources more than it demonstrates the truth of any supernatural claim.

Religion as Moral Leadership

Many religious leaders are wonderful people: warm, generous, giving, gentle, and wise. They can motivate others to focus on positive values, inspire acts of kindness, encourage a healthy lifestyle, and even exert political influence as peacemakers or as voices standing up to injustice.

On a small or local scale, a church minister, rabbi, priest, or imam may be a gentle and respected pillar of the community, organizing acts of kindness, comforting people in need, mediating conflicts, and providing counseling.

On a larger scale, some religious leaders have offered profound moral leadership on the world stage. Desmond Tutu, the Anglican archbishop from South Africa who helped lead his country peacefully out of the apartheid era, was one of the great moral figures of the late twentieth century. Mother Theresa, a Roman Catholic nun, was beloved for her profound acts of charity. Thich Nhat Hanh, a Vietnamese Zen monk, spread a message of compassion and peace. The Dalai Lama, the spiritual leader of Tibetan Buddhism, has become a global symbol of nonviolence, gentleness, and compassion. Dietrich Bonhoeffer, a German Lutheran pastor, drew on his Christian theology to resist the Nazis, ultimately leading to his execution in 1945. Rabbi Abraham Heschel used his standing as a Jewish theologian to combat racism and support the civil rights movement. Abdul Sattar Edhi, a Pakistani Muslim whose charitable work followed a simple religious ethic of mercy and service, was one of the world’s great humanitarians. B.R. Ambedkar, the Indian intellectual leader who helped write India’s constitution, used a Buddhist framework later in his life to stand peacefully against caste-based discrimination. The current Pope, Leo XIV, is emphasizing a theology of peace, while other darker forces in the world use religious language and symbolism to support war. Bishop Mariann Edgar Budde, the Episcopal bishop of Washington, used the moral language of Christianity not to flatter power but to restrain it, calling on political leaders to show mercy toward people living in fear. There are thousands more examples—many of the greatest humans who have ever lived have been religious leaders or devout followers of a religious faith.

Religion as Psychological Comfort

Religious beliefs, services, and rituals have helped countless people cope psychologically with death and loss. You can have less fear about death—your own death, or the death of someone you love—if you believe that death is an entry point to another world, and that separation is temporary. 

I think it is a psychological skill, for any person, to practice acceptance of the fact that everything ends: every pleasant experience, every day and night, every song, every meal, every breath, every firework, every life, every mountain. They all have a beginning, a middle, and an end, and then they are gone—sometimes literally in a puff of smoke. It is entropy in action: one of the underlying realities of the universe. On some level, religion can interrupt that acceptance by bypassing finality with an imagined eternity. This calms fear. But it can also be a kind of avoidance—a comforting story that softens grief by blunting the truth.

It is easy to see, then, why the idea of “taking away” religion can feel like taking away a rich cultural inheritance and a shield against despair. Many people imagine that without religion they would be left adrift, empty, or nihilistic. I do not believe that is a necessary outcome, but I do believe it is a real fear—and a psychologically understandable one.

Religion & Persecution

There is another layer as well: persecution and trauma. Many individuals and communities have been oppressed because of their religion, sometimes brutally—often by other religious groups, including rival branches of the same tradition. This happened to my own ancestors, most recently in my grandmother’s generation near the beginning of the Soviet era. There were experiences of fear and brutality that she could never speak about for the rest of her life. Trauma can cement belief--or at least cement loyalty to the people, symbols, and stories associated with survival.  

Mind you, people who questioned the religious beliefs of their time have often been persecuted and executed through the ages. The point is simply that fear—whether fear of outside violence, or fear of internal exclusion—can make belief feel like survival.

Religion, Stigma, and Politics

Finally, we should acknowledge the stigma surrounding the word “secular.” To many ears, it evokes coldness: a painting devoid of color, music devoid of emotion. It can evoke memories of totalitarian states that discouraged religion. Some people equate secularism or atheism with nihilism, criminality, or a lack of moral grounding. Many believers sincerely think that without God there would be moral decay.  People who are religious benefit from its association with moral stability, regardless of whether the association is valid.    

Politics amplifies this. In many contexts, public piety is rewarded, and some leaders clearly perform religiosity to secure loyalty. Leaders with life histories that are far removed from traditional piety can simply hold up a Bible for a photo op—a performative gesture that successfully rallies support from religious followers by trading on the symbols of their faith. So it is politically beneficial to appear religious.  

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All of this is why critique of religion, to be intellectually honest, must begin with an honest accounting of religion’s benefits: the attachment, the community, the rituals, the moral vocabulary, the beauty, the refuge, the saintly leaders, the buffering against death.  These are good things, even when the supernatural claims do not align with the evidence. The political advantages of religiosity are also understandable.  Understanding these benefits is not a concession—it is a prerequisite for explaining why religion persists, and why leaving it can be psychologically and socially costly.

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The Psychology of Religion, Chapter 2: Mennonite Roots

My ancestors were part of a Protestant Christian denomination and cultural group known as the Mennonites, which originated in the Netherlands in the 1500s. While similar to other Protestant denominations, Mennonites stood out for endorsing pacifism and for avoiding participation in war, except as medics or to assist refugees. When I was young, I always admired this stance, though I have come to realize that there were situations, such as in World War II, in which this "conscientious objector" policy meant that other people had to risk or lose their lives for the greater good, while members of the church remained at home in safety—so my admiration for this pacifism became more mixed over time.  

There was cultural unity among the Mennonites, migrating together for hundreds of years, maintaining their language of origin, Low German (Plattdeutsch), and other shared traditions. Such cultural unity is admirable, but there are downsides, such as reduced genetic diversity leading to an increased rate of heritable diseases. In groups with a relatively small and insular founding population, marrying within the community is genetically comparable to marrying one’s third cousin—or even a closer relative than that if families are more tightly connected.

Many Mennonites migrated east from the Netherlands to maintain cultural and religious freedom, settling as farmers in Ukraine for over 100 years. Eventually, most relocated again—under the trauma and duress of war and persecution—to various regions in North America, such as southern Manitoba. Some Mennonite subgroups adopted practices comparable to the Amish, while most others became quite mainstream Protestant denominations, often leaning toward conservatism or fundamentalism, though some became more liberal or progressive. The branch my family was most recently part of was comparable to other common modern Christian Protestant denominations. As with many families, the culture of my family over many centuries has been shaped by its religious involvement. Faith traditions carried within a family become woven into its history, culture, and values. Much of this history is something to feel proud of.

During my childhood, we attended church frequently. For the most part, these were positive experiences. One virtue of weekly church attendance is the opportunity for moral reflection. Sermons contained messages about dealing with difficult issues or about being a better person. Some sermons appealed more to the intellectual side of the audience, with references to academic theologians or philosophers; others would appeal to the more emotional or sentimental side. Many contained moments of gentle humor or playfulness, and many deliberately reached out to children. Sermons were based on Bible passages, many of which were good foundations for moral reflection and also had a poetic quality. Members of the congregation would participate in the services, often volunteering to read the Bible passage aloud. I was frequently moved by stories about Jesus—a gentle, loving, humble, heroic figure who accomplished amazing, transformative things not through superhuman strength or military prowess, but through wisdom, love, and self-sacrificial devotion to others.

The congregation was always reminded to care for members who had experienced recent loss or illness, or to celebrate those who had experienced a recent joy, such as a marriage or birth. In some church services, perhaps during prayer or music, some people would become deeply absorbed, in a joyful, flow-like state. This kind of regular experience can be profoundly healthy: it offers structured moral reflection with an attitude of gratitude, service, and reverence, couched in a loving and supportive community. It encourages people to be aware of—and involved in—the joys and travails of other people’s lives.

However, this format favored people who could tolerate long stretches of stillness and conformity; for children with ADHD traits, learning differences, restlessness, or physical discomfort, many services would have felt stifling (I recall many unfortunate children during my childhood who were frequently scolded due to their impatience). I think this is one of the reasons why some modern fundamentalist churches, which put on a more exciting and emotionally dynamic show with charismatic preachers, rock bands, and other performers, have been so appealing, especially to the younger generation.

I also attended a religious high school, with significant exposure to daily religious practice and education. Once again, this was quite positive, since the teachers were for the most part kind, thoughtful people. The motivation of most of this education was to help students grow in kindness, morality, and ethical leadership while being humbly conscious of important local and global issues. However, I also noted that the frequency of bullying, conduct problems, and social ostracism among students was no different from what one would find in a public secular high school. Alongside educational content in religion, there were meaningful, enjoyable, and comforting practices almost every day, such as choral singing, “chapel time,” and opportunities for community volunteering. I only noticed major gaps in parts of the science and social studies curriculum years later.

At times my family went to a fundamentalist Christian camp in Minnesota for a summer holiday. I have fond memories of camping, being out in nature, camp songs, and friendly people. One family there had a wonderful little dog that I loved. I was excited about the use of tambourines by the musicians. People were engrossed by charismatic preachers and energetic sermons every day; many were in an almost trancelike state of excitement or passion fueled by group energy, music, and prayer. Some people would get baptized in the lake; for many, this was emotionally moving and transformative (“born again”), accompanied by tears of joy.

In my young adult life, I also appreciated the philosophical contributions of many religious thinkers. C.S. Lewis was a favorite (following a pleasant introduction during my early childhood, reading his children’s books aloud with my mother), as were Kierkegaard and Bonhoeffer. In my final undergraduate year, I took a course covering historical theology and its manifestations through art and literature, looking at Western religious themes through the ages. This course became one of my intellectual foundations, resonating with my personality and interests, and combining the study of philosophy, art, literature, and history to deepen my understanding of the world.

Prayer and other symbolic actions can have a peaceful, meditative quality which is psychologically beneficial. It can be comforting to know that someone is praying for your well-being, and it can feel meaningful to pray for someone else’s well-being. (However, controlled studies, such as Benson’s 2006 STEP study, have not found reliable benefits of intercessory prayer beyond placebo effects).

Many church buildings are enjoyable spaces due to their architecture and acoustics, and their association with calm, comfort, safety, refuge, and transcendence. Church buildings in much of the world have historically been architectural gems in the middle of communities, sometimes the most visible or distinctive physical feature of the neighborhood.

I want to emphasize that I did not have a negative or bitter experience of religion in my childhood that led me to my current stance on this subject. There must be great respect and sensitivity for the many intimate, positive experiences of cultural enrichment and meaning that religion—or what others might call “spirituality”—brings to people in their own life history and in their family history.

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The Psychology of Religion, Chapter 1: Introduction

Religion has been woven through my life from the beginning—Mennonite ancestors, a gentle church-going childhood, and a religious high school. Yet as I learned more about science, nature, and humanity, I moved away from the religious ideas I internalized in childhood. While spiritual traditions can be psychologically rich and culturally beautiful, their literal supernatural claims are not true. And despite their capacity for building community and moral leadership, religions have also caused profound harm to both individuals and society. The chapters that follow move from my personal history to the psychology of belief, a review of what science teaches us about natural history, then to the social harms of dogma, and finally to a reflection on how to preserve the positive aspects of religion.

During my childhood, I was drawn to many attractive features of religious life: the warmth of a "church family," an altruistic focus on service, and striving towards ideals—love, justice, forgiveness—personified in a gentle, loving deity.  Choral music and camp songs, and the ready-made social world of youth groups, offered instant belonging to anyone willing to speak the language of faith.

For many whose faith lies outside the realm of organized religion, magical or mystical beliefs—fate, spirits, psychic phenomena—can create a feeling of specialness and awe. They suggest that hidden powers might guide destiny through an often confusing and unjust world.

In this essay, I aim to balance deep respect for the ways faith offers community, moral reflection, and "nonspecific" therapeutic factors—ritual, belonging, empathic attention—alongside a critique of dogma. Immense harms follow when sacred narratives are treated as facts or as rigid moral law.

Religious belief thrives on the same psychological mechanisms that render us vulnerable to misinformation or propaganda: above all, the primal pull of group allegiance. Our beliefs grow roots that interweave with our social identities. The belief system becomes a costly emblem of tribal loyalty, pushing us to selectively seek confirmatory evidence and to discount or avoid evidence to the contrary. This loyalty offers many benefits—friendship, structure, material support, and safety—but at the price of intellectual narrowness. This process is not uniquely religious; it is an ordinary human tendency that religion can intensify and sanctify.

In some fundamentalist communities, especially in North American settings, the same structures that create warmth and solidarity can harden into exclusion. These groups are often condescending or suspicious towards outsiders, selectively resistant to scientific consensus, and tend to align tightly with political identity. They may buffer loneliness for insiders while amplifying prejudice. The conviction that one’s group possesses divinely mandated truth creates pressure to treat other traditions as inferior—a recipe for arrogance that weakens the opportunity to learn with humility from other cultures.

Drawing on evolutionary biology, neuroscience, history, and my clinical experience as a psychiatrist, I explore why people so readily defend spiritual beliefs and how they can both heal and injure. Understanding the natural world—from evolution to astrophysics to the brain—does not have to leave us nihilistic, in fact I feel that appreciation of science deepens our humanity.  We can preserve the best ethical and communal aspects of religion without accepting its fictions as literal truth.

Faith is deeply shaped by identity, and this process develops over a lifetime; accepting evidence that challenges this identity can feel like betraying one's community. So it can be tempting to stick to the status quo within one's faith system.  However, a process of questioning dogma can lead to a better life for both individuals and for groups. Ironically, some of the greatest wisdom in sacred texts invites us to humbly reflect upon our blind spots, and to transform ourselves for the greater good.

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Reflections on Pandemic Management

During the pandemic I wrote a lot, in terms of analysis and encouragement of public health measures.  Some of my contributions were on this Blog, others were on Twitter.  To this day, I think that the measures taken to manage the pandemic were for the most part necessary and successful, for example restricted activity, masking, and vaccine policy.  

The COVID vaccines in particular have been one of the great achievements in the history of medicine.  

But here are some ideas about ways I think it could have been done better: in sharing this I know I run the risk of dabbling into territory that many would consider outside my lane of expertise.  That was a constant frustration for public health experts during the pandemic.  

However, I was conscious all the way through the pandemic that we did not adequately use the most powerful tool available in science and medicine to evaluate the effectiveness and optimize the efficiency of an intervention: the Randomized Controlled Trial.   

And also in dealing with people who were extremely resistant to adopting mandated restrictions or vaccines, there could have been a way to manage this situation that would have helped rapidly gather much better data about COVID itself, protect the population, while also appeasing people who did not want to get vaccinated or follow restrictions.  

Randomized Controlled Studies (or "Randomized Controlled Trials -- RCTs") 

There were many RCTs during the pandemic, but in my opinion there could have been much more done here, in almost every stage, and there could have been massive public investment to get this done, which subsequently could have saved billions of dollars of economic loss, in addition to saving lives.  

For example, it was very clear from basic science knowledge that masking was valuable to reduce viral contagion.  When some people raised the idea of doing more RCTs on masking, it was met with some resistance, as though we were wasting everyone's time in a dangerous way.  Some used a comparison with doing an RCT of using parachutes when jumping out of an airplane -- obviously this would be recklessly inappropriate, and the entire placebo group would die!  Masks, like parachutes, are obviously effective, and mask proponents made a reasonable case that randomizing people such that a placebo group would not get masks would be needlessly dangerous.  But an RCT does not require that there be a "placebo" wing!  It only requires that the study be randomized to compare one treatment with another.  To follow the parachute analogy, it could be to randomize people jumping out of an airplane to receive one of two different types of parachutes, each of which an accepted standard; or for them to use two different timings for releasing parachutes, if each of these was also within an accepted standard.   

In the case of masks, there could have been RCTs of using different types of masks (e.g. procedure vs. N95), different timings of masking (indoor only vs continuous outside the home), or different replacement times for masks (e.g. re-using N95 masks for days vs replacing them every use), or different N95 use details (e.g. receiving formal instruction on technique vs. not).  And early in the pandemic there was an N95 shortage.  One of the ways to deal with this could have been to randomly distribute the timing of the N95 supply, so that some entire communities would receive an adequate supply first.  Then the entire community would use N95s while adjacent communities would temporarily make do with other types of masks.  Then the disease prevalence rates and hospital admission rates could have been compared between adjacent communities.  This type of design could have been tremendously valuable, since mask use has not only an individual benefit for infection control, but has a collective impact, akin mathematically to the effect of vaccines -- if everyone in the population has a modestly reduced probability of infection, then it could translate to a massive reduction in community prevalence.  If such a study had shown reduced infection and hospitalization rates in the better masked areas, it could have propelled a much more urgent and timely effort to manufacture better masks for everyone, and in the medium term the whole community could have had better access to N95s, saving thousands of lives.   But since such studies were lacking, there was enough doubt about mask effectiveness or effect size to delay the massive investment needed to increase mask production.  

When RCTs are done, it does not settle questions once and for all: in good science, we are always repeating, tweaking, and refining.  New RCTs would have to be done after the first ones, with different details being looked at, or simply for replication.  

One type of mask use behaviour which should have been better guided by evidence, is the use of masks outdoors.  I still see many people outside with their masks, or people wearing them in their cars on the way to work.  It was pretty clear from the ventilation evidence that outdoor mask use was very likely unnecessary, unless one were in very close proximity to crowds, or doing a lot of talking up close.  Perhaps masks would still be needed in playgrounds etc. but certainly not for walks at the beach alone or with just a few people close to you.  

Similarly, RCTs could have been done on ventilation control in buildings.  The basic science on ventilation was one of the most important and underappreciated areas of science during the pandemic.  There was a wonderful group of engineers who had done great work in this area.  Ventilation improvement was also a totally non-controversial intervention:  regardless of one's views about masks or vaccines or restrictions etc., I think everybody would welcome the idea of having better fresh air inside our homes and workplaces.  Ventilation improvements involved air filtration (such as with HEPA or MERV-13 HVAC filters) but also increased fresh air replacement rates.   But the engineers again used the parachute analogy when there were challenges to do RCTs, arguing that their work was established basic science, which didn't need to be tested in an RCT.  But once again, if RCTs had been done, of whole communities which made ventilation improvements, vs communities which did not, we could have much more quickly found a "signal" of improved infection control, and then made much more rapid investments in ventilation improvement technology for everyone.  

In all of these studies, the data to gather should always have been not only rates of infection, but also most importantly rates of severe disease.  Some interventions such as masks arguably could cause a reduction in infection rate, but perhaps in cases of people getting infected despite mask use, they would have inhaled a smaller inoculum, and possibly could subsequently have developed milder disease, since the immune system would have had a little bit more time to respond to the virus before getting overwhelmed.  The question of whether inoculum size impacts disease severity is yet another one which I don't think is well-enough answered by the research.  

The Covid Hotel 

The "COVID hotel" idea was something I proposed early on as a thought experiment at the very least, and there was at least one other scientist in the US who shared this idea as well... but it was received very coldly by experts--when I gently suggested it I got the sense that they thought it was scandalously inappropriate or unethical.  But this idea could have saved thousands of lives, and could have helped gather optimized, crystal-clear data about COVID in terms of the mechanism of transmission, the effectiveness of masks, the impact of ventilation, etc.  This information could have been obtained within a few months, and then could have helped focus optimal interventions with much better clarity and urgency, and to mobilize public investments in such things as masks etc. much sooner.   

Here's the idea: if people refused to be vaccinated, or insisted on having unrestricted freedoms, instead of punishing them using the justice system, they could instead opt to check into a "covid hotel" in which they would choose, with informed consent about risks, to be deliberately infected with COVID under controlled conditions, with optimal medical support available.  Then they would stay in the hotel for a few weeks under quarantine until they were no longer infectious.  Upon checking out, they would have a much lower risk of spreading COVID--the risk would be comparable to a person who had been vaccinated.  In this environment, there could be meticulously controlled experiments to determine if COVID could be transmitted through an airborne route (perhaps all the time, perhaps only in some cases of "superspreaders" etc.), or through a surface contamination route (after all this time, it is not crystal clear that surface contamination was ever a major route of spread).  And there could have been masking studies in this environment to determine if masks (including styles of mask usage and mask type such as N95 vs procedure masks, as well as the proportion of people wearing masks,  etc.) reduced the likelihood of contagion, or reduced the ensuing severity of disease (since the masks even if they didn't prevent infection might at least reduce the inoculum size).  Similarly there could have been meticulous ventilation control studies, to see if improved ventilation reduced contagion.  

In this environment, participants could even be offered to choose modalities of treatment of their choice, delivered by their practitioner of choice. They could try the "alternative treatments" in vogue if they wished, or opt for standard medical care.  This way, there could have been much more rapid evidence to establish the impact of these alternative treatments (all of these alternative remedies have been utterly disproven, but this could have happened much more quickly and persuasively in the "COVID hotel" environment).  

Some of the benefits of this idea would have been much, much better quality data about mask effectiveness, mode of contagion, effectiveness of ventilation improvement, etc.  And there would have been much less spreading of COVID to vulnerable people by people who refused to adhere to public health guidelines.  And there would have been much less upset from people who wanted more freedoms.  In fact these people, instead of being vilified, could have felt like true heroes, even from a scientific point of view.  The cost of this, of course, would have been that people who chose the "COVID hotel" route would have been much more likely to die, or to have severe long-term consequences of COVID.  But this would have been their choice, and if they didn't check into the COVID hotel, they would have subjected themselves to the same risk in the community, with less medical support and therefore an even higher likelihood of medical harm, and all the while they would have spread COVID to many more people, without contributing anything useful to the world's knowledge about the disease.   There are many other examples in life of people who are willing do risky activities, following informed consent: for example, joining the military, the fire department, or doing risky sports such as hang gliding.  

Animal Studies

There were animal studies during COVID.  It's a sensitive topic, since it is important to respect the rights of animals.  But COVID affected the animal world as well, and the research about contagion would have led to benefit for not only human populations but animals as well.  One very particular type of animal study that was never done well enough was to use an animal model to demonstrate spreading modality.  For example, the ventilation outflow from hospital rooms with human COVID patients could have been pumped into an animal enclosure of susceptible animals.  If these animals developed COVID it would have been tremendously strong evidence for airborne transmission in humans.  If, in a follow-up experiment, the same ventilation pipe passed through a HEPA filter first, and then into the animal enclosure, and if these animals did not contract COVID, it would have been incredibly powerful evidence that a simple filtration technique could prevent contagion.   If animals were simply allowed to visit hospital rooms where COVID patients had spent a few days, but who had left, and where the air in these rooms had been replaced using ventilation, then it could have helped determine if surface contamination unequivocally could cause COVID spreading.  It is quite possible that surface spreading was never a major problem, while airborne spreading was a huge problem, hence efforts would have been directed towards ventilation rather than as much surface cleaning.  But we would have needed the research to prove this.  

Vaccine / Restriction Timing

Restrictions were deployed in the pandemic quite wisely, particularly with a view to prevent the nightmare of ICU and hospitalization overflow.  For some individuals, going beyond mandates, they voluntarily maintained restrictions for months or years following vaccination.  One interesting study issue could have been to randomize people to maintain strict restrictions after vaccination for a long period of time, vs. ending restrictions for those people starting about 4 weeks after each vaccination.  This would have caused the unrestricted individuals to have greater exposure to ambient circulating COVID strains, but this would have occurred in the context of good immunity.  As the vaccine strains kept changing, the vaccinated people would continue having new exposures with new strains, and especially as 3-6 months passed after their vaccines, they most likely would have had some mostly mild cases of COVID along the way.  But I wonder if this process would have in the long term led to improved, robust immunity to multiple strains, with the same or lower long-term health risk, while also improving community freedoms, compared to the situation of maintaining continuous long-term restricted behaviour.  In a sense, this idea would suggest that the vaccine and annual boosters would be the primary preventative defense, but then exposures to the ambient COVID strains in the community would subsequently act as "boosters" for previously vaccinated people, and in the long term (measured over 3-5 years or more) lead to equivalent or better health outcomes, with fewer restrictions needed.  Conversely, the studies might instead show that maintaining more restrictions over the longer term would have led to better long-term outcomes.  We can't know for sure, since the studies were never done.

Unfortunately, in the aftermath of the pandemic, there has been increased polarization in the world about public health measures of all types.  We are seeing decreased rates of vaccination against other diseases, and we are seeing a return of various diseases which had previously been nearly eradicated, such as measles.  Just as with Covid, most people who get these diseases will recover ok, but there will be needless cases of severe disease and death, including among young children.  I hope that the field of public health can work hard on the sociopolitical aspects of their profession as well as the epidemiological parts.  But I also wish that some of the best scientific tools, such as RCTs, could be done much more quickly and on a much larger scale than what we saw during the worst years of COVID.