The Great Mask Debate

Confused messaging and contending facts feed division over mask requirements

(r.classen/Shutterstock)

A fierce public debate about face masks is just one more bizarre feature of 2020. One side sees masks as a personal responsibility necessary to stop, or at least slow, a deadly contagion, and anyone who dares to go without is endangering lives. The opposing side sees mask requirements as an empty gesture and annoying charade that only serves to amplify panic.

The problem is that both sides can find supporting statements from the same sources.

Contradictory messaging from public health authorities planted seeds of discord in the early days of the pandemic. On March 8, infectious disease expert and a familiar face in the U.S. government’s COVID-19 response, Dr. Anthony Fauci, told 60 Minutes, “There’s no reason to be walking around with a mask.”

Dr. Theresa Tam, Canada’s chief public health officer, also advised against wearing masks for those who are healthy. “What we worry about is actually the potential negative aspects of wearing a mask, where people are not protecting their eyes or other aspects of where the virus could enter your body, and that gives you a false sense of confidence,” Tam said at a press conference in March.

Similarly, the U.S. Centers for Disease Control and Prevention (CDC), stated that masks were to be worn exclusively by the sick and their caregivers, and the World Health Organization (WHO) stated: “There is no specific evidence to suggest that the wearing of masks by the mass population has any potential benefit. In fact, there’s some evidence to suggest the opposite in the misuse of wearing a mask properly or fitting it properly.”

In April, experts abruptly changed course, emphasizing that everyone should now wear face masks in public. Health officials clarified that previous statements were made in an effort to save the masks for medical personnel working in close proximity to infected patients.

According to Morton Tavel, MD, clinical professor emeritus at Indiana University School of Medicine, the top-down conversation around masks has become a “case study in how not to communicate with the public.”

“The message became counterproductive and may have encouraged even more hoarding because it seemed as though authorities were shaping the message around managing the scarcity rather than confronting the reality of the situation,” Tavel said.

Another way some experts botched the mask messaging, Tavel said, is by informing the public that only well-fitted, medical grade respirator masks (such as the N95) could effectively protect against a virus.

“Many people also wash their hands wrong, but we don’t respond to that by telling them not to bother,” he said.

U.S. states allow virtually anything that covers the mouth and nose—from high-grade medical masks to bandanas and scarves—to satisfy mask requirements. Tavel says that while some masks may be better than others, they all provide some barrier of protection against respiratory droplets that potentially carry the virus.

The change in mask messaging came with an evolving understanding of COVID-19. Health experts began seeing signs of so-called asymptomatic carriers who could inadvertently spread coronavirus. This meant that even someone who appeared to be well carried a threat of infection wherever they happened to breathe.

But this key justification for public mask requirements also suffers from shaky messaging. In a WHO news brief on June 8, infectious disease epidemiologist Dr. Maria Van Kerkhove stated that the spread of the virus by asymptomatic carriers “appears to be rare.”

“We have a number of reports from countries who are doing very detailed contact tracing. They are following asymptomatic cases, they are following contacts and they are not finding secondary transmission onward, it’s very rare,” Kerkhove said.

A few days later on a Facebook Live video, Van Kerkhove clarified that there were “misunderstandings” attached to her previous statement. She explained that asymptomatic people can in fact spread the virus, though the degree to which they can is unknown.

No Scientific Consensus

These days, Dr. Fauci is an unwavering proponent for everyone wearing a mask in public. In an interview with CBS News, Fauci blamed most of the recent “burst of infections” across the nation on American’s failure to follow recommended health guidelines.

“Clearly, we have not succeeded in getting the public as a whole, uniformly to respond in a way that is a sound scientific [response to a] public health and medical situation,” Fauci said.

Those on the pro-mask side say that science guides their judgment, and they have the research to prove it. In May, preliminary results from a study on hamsters in Hong Kong determined that wearing a mask dramatically reduces viral spread.

Researchers found that the coronavirus’ transmission rate via respiratory droplets or airborne particles dropped by as much as 75 percent when surgical masks were used.

But the scientific case for masks is hardly a consensus. In an article titled “Universal Masking In Hospitals in the COVID-19 Era” a group of physicians wrote in the May edition of the New England Journal of Medicine, that wearing a mask outside health care facilities offers little, if any, protection from infection.

“Public health authorities define a significant exposure to COVID-19 as face-to-face contact within 6 feet with a patient with symptomatic COVID-19 that is sustained for at least a few minutes (and some say more than 10 minutes or even 30 minutes). The chance of catching COVID-19 from a passing interaction in a public space is therefore minimal. In many cases, the desire for widespread masking is a reflexive reaction to anxiety over the pandemic,” doctors wrote.

On July 16, an article in the Journal of Pediatrics and Child Health asking the question “Do facemasks protect against COVID-19” found that masks may cause more problems than protection. Researchers concluded that there was “no good evidence that face masks protect the public against infection with respiratory viruses.” In fact, masks may only offer the “illusion of protection,” and many mask wearers may simply be spreading disease because of how they use them.

“Surgical facemasks are designed to be discarded after single use. As they become moist they become porous and no longer protect. Indeed, experiments have shown that surgical and cotton masks do not trap the SARS‐CoV‐2 (COVID‐19) virus, which can be detected on the outer surface of the masks for up to seven days. Thus, a pre‐symptomatic or mildly infected person wearing a facemask for hours without changing it and without washing hands every time they touched the mask could paradoxically increase the risk of infecting others,” researchers wrote.

When the Association of American Physicians and Surgeons looked at mask efficacy they concluded that “the wide use of masks by healthy people in the community setting is not supported by current evidence and carries uncertainties and critical risks.”

Headaches, respiratory acidosis, dizziness, anxiety, and a decrease in oxygen saturation are some of the risks that doctors and researchers have associated with prolonged mask wearing.

One problem is that, the more effective the mask, the more risk associated with prolonged use. This means that the masks that work best at blocking microscopic particles also make respiration more difficult.

This is why orthopedic spinal deformity surgeon Dr. David Hanscom has very mixed feelings on which masks the public should wear.

“The size of the virus is much smaller than cloth masks and it does pass through it, but the more robust masks are not tolerable,” Hanscom said.

However, Hanscom does support wearing any face covering indoors in public spaces, even if the protection it provides is minimal. He says at the very least, it keeps people mindful of the pandemic.

“It does change behavior and reminds people to practice social distancing, which does seem helpful,” he said.

Common Sense

In the middle of a crisis, with so many lives at stake and unpredictable factors to consider, it’s understandable that the official response may not always be smooth. But when it comes to this pandemic, some advice defies logic.

In early June, for example, more than 1200 health professionals submitted an open letter in support of the gatherings protesting the killing of George Floyd by police. The letter spoke in support of “demonstrators’ ability to gather and demand change,”  but stated that it “should not be confused with a permissive stance on all gatherings, particularly protests against stay-home orders.”

Another point of public divisiveness is a patchwork of differing regulations and requirements. In some jurisdictions, masks are mandatory in public indoor spaces, while in others they’re merely recommended. In states where masks are optional, stores can choose to either have a relaxed policy and risk criticism from customers who may spy maskless shoppers, or make masks mandatory and risk discriminating against customers who can’t medically tolerate a mask or lose customers who choose to go maskless.

Numbers play a big role in our understanding of how to deal with this virus, and what measures each state takes as the pandemic unfolds. And yet even with something as solid as figures, this is another aspect of the crisis where the message is murky.

Dr. Dana Cohen, an integrative physician practicing in Manhattan, says she has a hard time seeing a clear picture, even as a doctor.

“I don’t know what numbers to believe,” Cohen said. “There are people who are getting tested three times a week. If they’re positive, they'll be positive multiple times. And all are counted as separate positives.”

Cohen mentions aspects of the virus itself that defy models and previous patterns of infection. For example, we’re now seeing case surges that weren’t expected until this fall. But she adds that even though the truth is hard to see doesn’t mean we should abandon basic common sense.

“I don’t think people should be going to concerts, or be close together marching and shouting. That’s not common sense. It’s not cool,” she said.

Like much of the public, Cohen says she has also been puzzled by the official response. For example, while masks get all the attention, hand washing and physical distancing are much higher priorities in the effort to stop viral spread. Cohen also advocates for other measures that receive hardly any attention, like employing daily strategies that can help strengthen our immune systems.

“Nutrition is the most important thing,” she said. “I wish that our government was more concerned about giving kids better food and vitamin D, especially for the kids that can’t afford it. That should be more mandatory than masks. It’s proven that the people with the poorest immunity have the least resilience. It’s turned out to be a disease of lifestyle, and we’ve known this for months now.”

To its credit, the CDC did make a statement on July 12 that good nutrition plays a role in the pandemic, “as certain vitamins and minerals may have effects on how the immune system works to fight off infections and inflammation.”

Health Canada has not made a similar statement.

Think of Others, Don’t Antagonize

In jurisdictions where the lockdown is lifting, there are signs of life returning to normalcy. More public spaces are opening up, but new mask requirements have come along for the ride. Cohen advises always erring on the side of caution, but adds that we should also evaluate each situation individually.

“I would not exercise in a mask, because I think that’s a little dangerous. But I would also not exercise in a gym full of people. So you have to find what’s going to work for you. Maybe exercise in your home,” Cohen said.

Even in the strictest jurisdictions in the United States, not everyone is required to wear a mask. The CDC states that “face coverings should NOT be worn by children under the age of two or anyone who has trouble breathing, is unconscious, incapacitated, or otherwise unable to remove the mask without assistance.”

Health Canada advises wearing a non-medical mask or face covering when indoors in public spaces where you can’t keep a physical distance of 2 metres from others.

But how do you tell among the maskless faces you might encounter in the local hardware store who genuinely can’t tolerate a face covering, and who just doesn’t want to be bothered?

Cohen’s advice: Don’t worry about it. Instead, avoid confrontation, regardless of how strong your stance on masks might be. She says those who shout at or try to publicly shame the maskless for failing to follow the rules are only hurting the situation.

“People need to stop being the mask police. Don’t scream at somebody across the street to put your mask on. Mind your own business. Let people make their own decisions. If you are that worried about yourself, wear better face masks and a shield. This is not something to lose friendships over. Nobody is purposely trying to hurt anybody here,” she said.

By the same token, Cohen says that those who oppose masks should also show some compassion for the pro-mask crowd, particularly if they find themselves in close proximity. Give them space. Don’t antagonize. Consider that these people may be terrified because of what they’ve read, and struggle with underlying conditions.

“Be a little neighborly,” Cohen said.

Dr. Bonnie Henry, British Columbia’s Provincial Health Officer, has garnered international praise for her handling of the crisis.  Her mantra, repeated frequently, has become more relevant as public tensions have risen over issues like mask wearing.

“Be kind. Be calm. Be safe,” she advises.