Why Wear a Mask?
An organization called Masks Save Lives is currently calling out a link between “low mask acceptance cultures” and how badly COVID-19 outbreaks are affecting these areas and their failures to flatten the curve once outbreaks began. Research potentially supports this division, a 2009 study in Australia found that the data could not be assessed for if cloth mask usage reduced seasonal infections in the public due to low compliance by participants.
The CDC now recommends wearing masks and numerous websites have come out with instructions on how to make a cloth one (here’s one!). [update 15 July 2020] A new study by the CDC also found significant reduction of transmission from 2 symptomatic hair stylists that tested positive for COVID-19, but all 139 exposed clients were protected by both the stylist and the clients wearing masks. With all this information available there are individuals still refusing to wear masks and the argument is that the reason for this denial is rooted in our culture.
Is there something to the cultural divide? We’re going to look at the United States, specifically (though the next Tweet is from the UK).
Why Do People Not Wear Masks?
Mask acceptance is not as easy as mandates and public health advisories. Beyond the scientific and home care acceptance, it must not be seen as a threat. Previously the lack of compliance in the Australian study may have been related to an element of social acceptance, however this was not studied at that time. If someone is uncomfortable wearing a mask they won’t. One community that may feel this impact are ethnic and racial minorities in the United States. One 2010 study investigated the barriers to mask wearing among urban Hispanic households in cases of upper respiratory infection. The findings concluded that these communities required higher risk perception scores before adopting face mask usage. This led the researchers to conclude that face masks are unlikely to be effective for this community in the case of seasonal or pandemic influenza like conditions. The participants voiced concerns about social acceptability of masks within their communities – if they would be viewed as the source of illness – while others mentioned potential embarrassment.
Many have long dealt with violence related to the use of masks. Assumptions related to suspicion of crime, gang activity, and other racial profiling can making wearing a mask uncomfortable.
A recent paper in the Lancet mentioned
Consideration should also be given to variations in societal and cultural paradigms of mask usage. The contrast between face mask use as hygienic practice (ie, in many Asian countries) or as something only people who are unwell do (ie, in European and North American countries) has induced stigmatisation and racial aggravations, for which further public education is needed. One advantage of universal use of face masks is that it prevents discrimination of individuals who wear masks when unwell because everybody is wearing a mask.
At this time the adoption of universal mask usage in the United States is tenuous and has been unnecessarily politicized.
In the state of Virginia it is illegal to wear masks in public, though after the CDC’s announcement the law no longer applies.
§ 18.2-422. Prohibition of wearing of masks in certain places; exceptions.
It shall be unlawful for any person over 16 years of age to, with the intent to conceal his identity, wear any mask, hood or other device whereby a substantial portion of the face is hidden or covered so as to conceal the identity of the wearer, to be or appear in any public place, or upon any private property in this Commonwealth without first having obtained from the owner or tenant thereof consent to do so in writing. However, the provisions of this section shall not apply to persons (i) wearing traditional holiday costumes; (ii) engaged in professions, trades, employment or other activities and wearing protective masks which are deemed necessary for the physical safety of the wearer or other persons; (iii) engaged in any bona fide theatrical production or masquerade ball; or (iv) wearing a mask, hood or other device for bona fide medical reasons upon (a) the advice of a licensed physician or osteopath and carrying on his person an affidavit from the physician or osteopath specifying the medical necessity for wearing the device and the date on which the wearing of the device will no longer be necessary and providing a brief description of the device, or (b) the declaration of a disaster or state of emergency by the Governor in response to a public health emergency where the emergency declaration expressly waives this section, defines the mask appropriate for the emergency, and provides for the duration of the waiver. The violation of any provisions of this section is a Class 6 felony.Code 1950, §§ 18.1-364, 18.1-367; 1960, c. 358; 1975, cc. 14, 15; 1986, c. 19; 2010, cc. 262, 420; 2014, c. 167.
Masks And Accessibility
I was unable to find documentation online of how those with disabilities that inhibit the use of masks are handling the situation or even recommendations for these individuals on how to stay safe.
Update 14 July 2020: recommendations currently stand that individuals requiring modifications to wear masks should instead self isolate and not wear the mask. These are not going to be the people attempting to show a printed off the internet ADA card while not social distancing and yelling about their rights. These individuals may have a medical letter from a doctor explaining the specifics of their condition, but this does not exempt them from wearing masks inside commercial businesses. It instead requires businesses to make accommodations, such as curbside pick up or delivery. According to the Southeast ADA Center individuals that should not be wearing masks for accessibility reasons include:
- Individuals who have any respiratory condition (such as COPD, asthma, and cystic fibrosis) that may be worsened by wearing a mask.
- Individuals who cannot remain calm and functional while wearing a mask due to PTSD, anxiety, claustrophobia, or other anxiety disorder. Masks have been shown to induce hyperventilation, elevated heart rate, and panic attacks in these individuals.
- Individuals with Autism/Autism Spectrum Diagnoses (ASDs). Sensory hypersensitivity can induce panic in response to having the nose and mouth covered, fabric textures, and the feeling of masks touching their faces.
- Mobility impairment that requires an otherwise independent individual to need assistance. Many people cannot make an assistive caregiver materialize out of nowhere and preservation of autonomy is really important.
- Anyone using mouth or tongue control devices. This includes motorized chairs that use the sip and puff control mechanism.
Masks For Children & Caregivers
In other cases we need to consider family caregivers, and children, both needing modifications and not. Many children struggle to wear masks, particularly infants and toddlers. The primary reason most experts encourage children to wear masks is to prevent them from giving it to others, rather than to prevent them from contracting the virus themselves. But the CDC still insists that all children over the age of 2 should be wearing a mask when they leave the house. I am looking for further resources – at this time I have heard about this problem from friends that are parents.
The American Academy of Pediatrics has released the following guidelines for masks and children with special health considerations:
-If you must go outside or to a place where you are not able to practice social distancing with an infant, cover the infant carrier with a blanket, which helps protect the baby, but still gives them the ability to breathe comfortably. Do not leave the blanket on the carrier in the car or at any time when the baby and carrier are not in direct view.
-Children who are considered high-risk or severely immunocompromised are encouraged to wear an N95 mask to best protect themselves.
-Families of children at higher risk are encouraged to use a standard surgical mask if they are sick to prevent the spread of illness to others.source: https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/masks-and-children-during-covid-19/
In terms of the minimum effectiveness and materials? An Experimental Study of Efficacy of Gauze Face Masks published in 1920 the researchers concluded that cloth masks had basic minimum requirements that had to be met in order for a mask to have a “restraining influence on the number of bacteria-laden droplets possible of inhalation”. Part of this involved a balance between the number of layers, thread count, and breathability. If the mask is too dense as a result of the layers and thread count then “breathing is difficult and leakage takes place around the edge of the mask”. That leakage of air is what they proposed caused the reductions in efficacy observed. Research such as this resulted in recommendations of a minimum of 300 thread count fabric still used today.
Cost Prohibitive / Unable to Obtain
We’ve talked about poverty before. This can impact obtaining supplies, time to make a mask, and many other life factors that are none of my business and we need to be understanding. Others are unable to sew or are unable to put a mask on for themselves (see “modifications” above).
Do Cloth Masks Really Help?
[Updated 14 July 2020]
Numerous papers have been published establishing the effectiveness of masks in the control of the SARS-CoV-2 virus. One paper in the Lancet is titled “The Rational Use Of Face Masks During The COVID-19 Pandemic”. This paper took the time to thoroughly analyze public health responses from various countries, the reasoning behind their responses, and how this impacted the spread of the virus. While it explains that stigma is likely to be the biggest barrier, there’s still sufficient evidence from countries that did adopt a universal mask wearing policy and slow the spread.
A paper published in the BMJ sought to do a systematic review of the effectiveness masks. While arguing the precautionary principle is a wise choice in regards to public health measures and does not require “perfect evidence” or a full systematic review prior to implementation.
In conclusion, in the face of a pandemic the search for perfect evidence may be the enemy of good policy. As with parachutes for jumping out of aeroplanes,38 it is time to act without waiting for randomised controlled trial evidence.39 A recently posted preprint of a systematic review came to the same conclusion.40 Masks are simple, cheap, and potentially effective. We believe that, worn both in the home (particularly by the person showing symptoms) and also outside the home in situations where meeting others is likely (for example, shopping, public transport), they could have a substantial impact on transmission with a relatively small impact on social and economic life.
In a letter to the editor published in Infectious Disease Modeling a group discussed disease modeling performed on data sets from New York and Washington states. What they found suggests that the adoption of wearing masks will decrease the number of deaths significantly and reduce transmission.
Hypothetical mask adoption scenarios, for Washington and New York state, suggest that immediate near universal (80%) adoption of moderately (50%) effective masks could prevent on the order of 17–45% of projected deaths over two months in New York, while decreasing the peak daily death rate by 34–58%, absent other changes in epidemic dynamics. Even very weak masks (20% effective) can still be useful if the underlying transmission rate is relatively low or decreasing: In Washington, where baseline transmission is much less intense, 80% adoption of such masks could reduce mortality by 24–65% (and peak deaths 15–69%), compared to 2–9% mortality reduction in New York (peak death reduction 9–18%)
We began asking this question a long time ago. In a 1920 study on gauze masks looking retrospectively at the data from the 1918 influenza pandemic regarding the infections contracted by healthcare workers, authorities’ primary criticism was that the weave of the fabric was too loose. Though the study still concluded that masks did not demonstrate to have a degree of efficacy that would warrant their compulsory application during an epidemic, they argued that masks should not be abandoned entirely. I’ll leave it in their words:
Studies made in the Department of Morbidity Statistics of the California State Board of Health did not show any influence of the mask on the spread of influenza in those cities where it was compulsorily applied, and the Board was, therefore, compelled to adopt a policy of mask encouragement, but not of mask compulsion. Masks were made compulsory only under certain circumstances of known contact with the disease and it was left to individual communities to decide whether or not the masks should be universally worn.
The reason for this apparent failure of the mask was a subject for speculation among epidemiologists, for it had long been the belief of many of us that droplet borne infections should be easily controlled in this manner. The failure of the mask was a source of disappointment, for the first experiment in San Francisco was watched with interest with the expectation that if it proved feasible to enforce the regulation the desired result would be achieved. The reverse proved true. The masks, contrary to expectation, were worn cheerfully and universally, and also, contrary to expectation of what should follow under such circumstances, no effect on the epidemic curve was to be seen. Something was plainly wrong with our hypotheses. We felt inclined to explain the failure of the mask by faults in its application rather than by any basic error in the theory of its use. Consequently, Bulletin No. 31* of the Board of Health brought out the fact that where it was sought to control influenza by compulsory wearing of masks certain obstacles developed. These were:
First, the large number of improperly made masks that were used.
Second, faulty wearing of masks, which included the use of masks that. were too small, the covering of only the nose or only the mouth, smoking while wearing, etc.
The American Journal Of Public Health.
Third, wearing masks at improper times. When applied compulsorily masks were universally worn in public, on the streets, in automobiles, etc., where they were not needed, but where arrest would follow if not worn, and they were very generally laid aside when the wearer was no longer subject to observation by the police, such as in private offices and small gatherings of all kinds. This type of gathering with the attendant social intercourse between friends, and office associates seems to afford particular facility for the transfer of the virus. If, as seems probable, the virus is droplet-borne, this form of contact, where people are conversing with one another, would, of course, be much more dangerous than crowd association of strangers, even under the circumstances of gathering in churches and theatres. We were not satisfied, however, with this seemingly perfectly satisfactory explanation. We felt it to be imperative, if the mask were not to be permanently discredited, that more definite information be obtained concerning its uses and limitations. If, as we believed, the gauze mask is useful as a protection against certain infections, it would be unfortunate if its uncontrolled application in influenza should result in prejudicing critical and scientific minds against it.
A 2008 Study that came out in PLoS One found that wearing homemade cloth masks reduced hypothetical infections after spraying people with a simulated contagion.
A 2011 review of “Physical interventions to interrupt or reduce the spread of respiratory viruses” found that …
Respiratory virus spread can be reduced by hygienic measures (such as handwashing), especially around younger children. Frequent
handwashing can also reduce transmission from children to other household members. Implementing barriers to transmission, such
as isolation, and hygienic measures (wearing masks, gloves and gowns) can be effective in containing respiratory virus epidemics or in
hospital wards. The more expensive, irritating and uncomfortable N95 respirators might be superior to simple masks. It is unclear if
adding virucidals or antiseptics to normal handwashing with soap is more effective. There is insufficient evidence to support screening
at entry ports and social distancing as a method to reduce spread during epidemics.
…meaning that isolation, hygiene, and barriers like masks were effective.
On a lukewarm note, a 2013 study found that they were “better than nothing” against droplet transmission during an influenza pandemic.
Health Belief Models are one of the most mad scientist or the most Psy Ops things about public health. How do you get an entire population to participate in something that will help everyone in the long run – like washing hands? In 2014, a literature review of cloth mask usage was published in the Singapore Medical Journal taking a different approach to the use of cloth masks in the context of a Health Belief Model.
Confusingly, and commonly cited by those against wearing masks, a later 2015 study in BMJ Open found
Cloth masks resulted in significantly higher rates of infection than medical masks, and also performed worse than the control arm. The controls were HCWs who observed standard practice, which involved mask use in the majority, albeit with lower compliance than in the intervention arms. The control HCWs also used medical masks more often than cloth masks. When we analysed all mask-wearers including controls, the higher risk of cloth masks was seen for laboratory-confirmed respiratory viral infection.”
With such mixed reviews being published, why wouldn’t we be hesitant to recommend masks when they’re being advised as only a last resort? Here’s the thing. We’re there. We’re at the last resort.
When is a mask not a good idea?
Masks can lead to inhaling your own infectious droplets from a sinus infection and spread it to the rest of your airways.
Here’s an anecdote. I am having trouble finding papers to support this, but this is the current hypothesis my immunologist and I have as to how I got that month long pneumonia in March 2020.
I had a sinus infection and I was wearing a mask. Then, I aspirated droplets from my sinus infection leading to a lung infection. This lung infection eventually developed into a pneumonia. This is an instance of when a mask is not a good idea. Circumstances when you can aspirate your own droplets from a sinus infection or from an oral infection would be while exercising, crying, or dealing with temperature or humidity swings that would result in a runny nose. That’s it.
Other people who should not wear masks? The CDC recommends against masks for anyone with breathing problems, such as shortness of breath, children under the age of 2, and “Anyone who is unconscious, incapacitated or otherwise unable to remove the mask without assistance.”
What About Herd Immunity
I added this section in the update because I have heard arguments against mask wearing for the purpose of increasing herd immunity. Quanta Magazine wrote a great article explaining that herd immunity is complicated and how to read an R0 . For those that don’t want to read the article, I will explain it in a way I’ve used in the past for students.
Imagine you have a bouncing ball rolling around on a pool table and every time that ball hits another ball it changes that ball’s color. This change is not reversible. The number of balls that can interact and change color at a given time depends entirely on factors such as movement, density, and the total area of the pool table versus the size of the ball. Any change in those conditions is going to change the probability of interactions, and as the balls change color there are fewer available. That said, you can always add more balls, and some of them might have already changed color. You can force the balls to not go anywhere and severely reduce their interactions.
Because herd immunity’s effectiveness is dependent on the R0 (The estimated number of people being infected by an infected person / the number of balls interacting with the balls that have changed color) and that number will vary based on the conditions previously mentioned.
Herd immunity does not protect vulnerable populations effectively due to heterogeneity of R0 within a single population. Not all humans behave the same and this vastly changes how many people they can potentially infect. With necessary herd immunity estimates requiring a range of 40-60% of the United States population to have been infected to impact and reduce the spread, and an estimated death rate range of 4-6% at this time we can quickly consider what this means for a population of 328.2 million.
This means a total of 131.28 – 196.92 million Americans will need to contract COVID-19. If this happens, we can expect 5.25 – 11.82 million deaths in total by the time herd immunity is achieved unless there is vaccine intervention, assuming the death rate does not increase beyond 6% due to lack of access to medical care as ICUs hit capacity across the United States.
- Wear a cloth mask. Assume good intent for everyone wearing a mask. They aren’t doing anything suspicious. Don’t call the police.
- Masks work. Please wear them, but wear them smartly. They do not make up for poor hygiene practices.
- Some people can’t afford the supplies to make cloth masks, or they need modifications for their unique needs, or they cannot make the mask themselves. There are resources for that.
- Children’s masks need consideration based on your child’s needs.
- Masks are not always a good idea. Inhaling your own droplets can lead to pneumonia not related to COVID-19.
Thank you for reading this. Without you I am shouting into an ether. If you enjoy and want me to write more of these, please share this or comment below with what you would like to see me write next.
I started writing this article on 8 April, 2020 and stopped because I needed a break from writing about coronavirus related topics. I will be continuing to update this post-publication. Last updated on 14 July, 2020.