I admit, I was nervous. I had about 30 minutes before I was needed in the operating room. My patient had active COVID-19, but needed emergency surgery. This was back in August 2020, pre-vaccine and mid-hysteria. I pushed the button for the basement. I hate basements.
As I walked in, the nurse was ready for me. I had to be form-fitted for my N95 mask. Form-fitting is critical for preventing any viral particles from sneaking in from the sides of the mask. I put the first one on. She then had me put a plastic hood over my head and upper body. She hooked up a tube and asked me to let her know if I sensed any bad smell or had any sour taste in my mouth. Within five seconds, I was sick from the sour taste in the back of my throat. She quickly stopped and we repeated the same test with another N95. This time, it took 30 seconds. Luckily the third N95 fit, with no sour taste or smell even after three full minutes.
I was ready.
I donned a form-fitted N95 mask, a bubble suit, double gloves, and goggles. It felt like I was in a bad movie, but this was really happening.
It’s now a year later and what have we learned about masks? Everything and yet nothing.
I was a co-author of a paper on N95 masks that was published in 2007 in the American Journal of Public Health. It was written by my brothers and niece, as well as myself. Yes, we’re all physicians. Dr. Martin Weiss was the lead author. It was titled “Disrupting the Transmission of Influenza A: Face Masks and Ultraviolet Light as Control Measures.”
One takeaway message from that article, which was written during the H1N1 scare, was that N95 masks can block 95 percent of particulate aerosols from penetrating into the mask, and we need to manufacture them now. They can block particles as small as 300 nanometers in size, which could block the COVID-19 virus.
Even though COVID is small enough to slide through the N95, the mask still has dense nanofibers that can catch droplets. In the operating room, it’s the best we have unless we have a full N 100 respirator. Still, the N95 can capture the virus when expelled from an infected person, according to an article published in Nature Medicine in April, 2020.
The sad part is that our call for mass production of these masks back in 2007 went unheeded. We also stated that the goal is vaccines and therapeutics. While we have vaccines, therapeutics are lagging far behind. Even discussing therapeutics is frowned upon now.
Today, we’re constantly bombarded by recommendations and even orders to wear masks when outdoors. Los Angeles County, New York, and St. Louis all are implementing indoor mask mandates—again.
There was a time when we were told to wear them outside, even if alone. I’ve even seen people driving alone in a car wearing a mask.
The problem with the best of intentions is that they can often lead to poor judgment. What constitutes a mask in the setting of COVID-19 restrictions? It’s worth unmasking masks.
Let’s start with N95, as I described above. To be effective, it has to be form-fitted. Not all N95’s fit properly, and they can leak viral particles. They’re actually called respirators, not masks. A mask mainly keeps the wearer from ejecting droplets or spray that affect others. A respirator provides two-way protection and can keep the wearer from catching aerosol particles from others.
There is even a N100, which does what it implies. N 100 can block out the COVID, but good luck wearing it for any length of time. N95 respirators aren’t comfortable, and I have trouble wearing them for long periods of time. You really don’t want your surgeon uncomfortable. A number of colleagues and I have had to stop surgery to wipe our faces and readjust our masks.
Surgical masks are made of three plied layers of synthetic microfibers and extra-fine synthetic fibers, which block out much larger particles, but do a poor job of blocking the much smaller particles associated with COVID-19 viral transmission. The COVID-19 virus is extremely small, 60-140 nanometers, which is 1/1000th of a micron. A paper, “Filtration Performance of FDA-Cleared Surgical Masks,” stated that “The results suggest that not all FDA-cleared surgical masks will provide similar levels of protection to wearers against infectious aerosols in the size range of many viruses.” It was published in the Journal of International Society of Respiratory Protection in 2009.
Surgeons wear surgical masks for two reasons. First, we don’t want any blood or bodily fluid to hit us in the mouth, and second, we don’t want our saliva or drool to spill into the wound. We don’t wear them for viral protection. To be fair, there are a few articles that claim some surgical masks reduce viral transmission, from the person wearing the mask, but that’s assuming that droplets are the main cause of transmission when they may not be. Some believe aerosol spray is the major factor.
Those studies also assume that there’s no leakage from ill-fitting masks, since those were controlled environment studies. Aerosol spray is the extremely small viral particles that an infected person would give off when breathing. Droplets would be slightly larger, but still minuscule, and found in the kind of spray you see in a sneeze or when someone is speaking or coughing. (A side note: Masks with ties are more effective than masks with loops since they give a better seal.)
We hear a lot about “droplets.” Droplets aren’t some raindrop-size spit coming out of a person. Scientists usually mean something less than five microns (1/5,000 of an inch). The vast majority of COVID-19 is spread in much much smaller aerosol spray of 1/1,000 of a micron.
Dr. Kevin Fennely published a paper in The Lancet in 2020, stating that most viral pathogens are found in small particles. This conflicts with the view that larger droplets are responsible for most viral transmission. There have been other studies showing that very small particles (under 5 microns in size) may contain as much as nine times as much virus as larger particles (droplets). It’s also postulated that these smaller particles may be more dangerous, since they can penetrate deeper into the lungs. As a side note, when a droplet falls to the ground, it becomes aerosolized and is still a problem.
Those who believe that droplets are the main source for COVID-19 infections should also then support social distancing, but not the six feet we’re told. To be accurate, it should be anywhere from 18 to 27 feet. No one really knows where this six-foot social distancing “rule” came from. It most likely arose from the 1918 Spanish flu outbreak. The World Health Organization (WHO) recommends social distancing at one meter (39 inches). This was based on work by a researcher from 1930 who studied the spread of tuberculosis. The Centers for Disease Control and Prevention recently changed the social distance requirements in schools from 6 feet to 3 feet (slightly less than 1 meter).
So, in effect, we’ve upended our entire world to enact policies with limited impact, meaning that the cost associated with implementing them isn’t offset by the proposed gains.
COVID-19 is bad. It’s absolutely horrible, especially if you’re older and have underlying medical conditions that make you more vulnerable. The good news is that, for most of us, it will only be a mild infection, such as the flu. The chance for a young person under 40 to die from COVID-19 can be as low as 0.01 percent and even lower if vaccinated.
The unintended consequences of the draconian measures from this pandemic are tragic. A recent report by The Well Being Trust says there could be 75,000 more deaths by what is called “death by despair” (suicide, drugs) because of COVID-19. Those 75,000 will be young people, not the elderly. In other words, people who aren’t really at risk from COVID-19.
We’re beset by misinformation and confusing recommendations from our government. Vaccines are amazing, I’m a believer, yet some politicians, such as President Joe Biden and Vice President Kamala Harris, publicly stated that they wouldn’t trust any vaccine coming out under former President Donald Trump, until they were in charge. Don’t wear masks, now wear masks. Wear two masks, since two is better than one. Vaccines will set you free, until they don’t. Therapeutics that can treat COVID-19 are frowned upon, and you must be evil if you even suggest the possibility. This isn’t a reliable information environment.
How we tell a medical story is critical for success. It’s the way we tell a cancer patient or a surgical patient how we’ll treat them that sets up a plan for success.
And that plan should be based on a rational balance of cost, reward, and freedom. We don’t force a cancer patient to get a treatment that will make them suffer and a similar argument could be made for the vaccine.
Even though I’m a believer in the vaccine, I understand those who aren’t and respect the right of a healthy 18-year-old woman to decline receiving it. For the 36 million people who have had COVID, there’s no need for them to get the vaccine, since they have natural immunity. For how long, we don’t know, but research suggests durable immunity. It’s simple to test and find out if you still have antibodies against COVID-19.
Back in 2007, we suggested that the nation stockpile N95 masks. No one listened. We’re now incapable of manufacturing those masks. They’re all made in China. So now, we can wear a cheesecloth mask, and we’re told that we’re saving our nation.
I personally have no problem with wearing a mask if and when it’s truly needed. It just has to be the right mask, an N95 or greater. And yet, these masks are distinctly uncomfortable and add an additional strain on your system. They make it harder to breathe, or in research terms, impede gaseous exchange. I often have to stop surgery to adjust my mask and “catch my breath,” I’ve been wearing masks for all of my professional life, so it’s easier for me. I’m not everyone, though.
The issue we have is defining when is mask-wearing warranted? Forcing vaccinated people, or those who have recovered from COVID-19 to wear a mask, makes little sense, other than making some people feel more secure. Forcing a 2-year-old to wear a mask is asinine, to say the least.
On top of that, mandates don’t work. The implied new goal of reducing the COVID-19 death rate to zero is unrealistic and will never happen. This is now endemic. If we mandate mask-wearing to “save” lives, then we might as well mandate prohibition, since there are an estimated 95,000 deaths per year from alcohol-related incidents. Many of those are from drunk drivers killing innocent bystanders or passengers. The same argument can be made here. Solutions need to be realistic, not ridiculous.
Our nation should be able to mass-produce something as simple as N95 respirators and distribute them to the nation when and if needed for some future catastrophe. There will surely be more pandemics coming. My point is, if we need a mask, make it something that works.
Cloth masks, or even surgical masks, are like tying a rope around your waist while driving and claiming it’s a seat belt.
It also isn’t too much of an exaggeration to say wearing a Gucci style face-covering, such as Nancy Pelosi has, is like asking an X-ray technician to wear their grandmother’s kitchen apron when taking X-rays.