A Canary in a COVID Coal Mine: Building Better Health-C are Biopreparedness Policy

Diemer and Swanson Reply to "Considerations Before Using Pandemic as Instrument"

Dimitris and Platt (Am J Epidemiol. 2021;190(11):2275-2279) take on the challenging topic of using "shocks" such as the severe acute respiratory system coronavirus 2 (SARS-CoV-2) pandemic as instrumental variables to study the effect of some exposure on some outcome. Evoking our recent lived experiences, they conclude that the assumptions necessary for an instrumental variable analysis will often be violated and therefore strongly caution against such analyses. Here, we build upon this warranted caution while acknowledging that such analyses will still be pursued and conducted. We discuss strategies for evaluating or reasoning about when such an analysis is clearly inappropriate for a given research question, as well as strategies for interpreting study findings with special attention to incorporating plausible sources of bias in any conclusions drawn from a given finding.