Wear a Mask, But Act as If It Doesn’t Work

As I write this on June 29, 2020, we are in the midst of a global pandemic with a scary, rapidly spreading new virus that we don’t understand very well yet. Globally, 10,199,798 have become infected and 502,947 have died, for a 4.93% death rate. In the U.S., 125,928 people have died out of 2,564,163 infections, for a 4.91% death rate. The bad news is that the actual number of infected people is very likely much higher, inasmuch as testing has been hit and miss, so that means the death rate may not be so high. Nevertheless, the raw number of deaths is a staggering figure and everyone is, or ought to be, worried about getting COVID-19. What can you do to prevent catching the disease?

The rational response would be to listen to expert advice and follow the best public health precautions to minimize the risk of catching or spreading COVID-19, which includes frequent handwashing, remaining isolated as much as you can, social distancing when out in public, and wearing a mask around others. But this relatively simple advice has morphed from a public health recommendation to a political hot-button issue. Medical experts recommend masks, for example, but the President sets a bad example by refusing to wear one. Medical authorities recommend social distancing, but people are still crowding together in many settings, and many of them are not wearing masks. Where this has happened in places that began to reopen in May, most notably Florida, Arizona, and California, COVID-19 has come roaring back. Here are some reasons why wearing masks is important.

Surgeons wear masks

Surgeons wear surgical masks for many hours a day, day after day. They don’t have any trouble breathing. They are well trained. They know they have to keep their meticulously scrubbed and gloved hands sterile. They know they can’t touch their eyes or their faces and must not touch the mask. If it needs adjusting, they get a nurse or technician to do if for them. If something itches, they know they mustn’t scratch; they ask someone who is not scrubbed in to scratch it for them. They tolerate the minor annoyances not for their own personal benefit, but for the benefit of others. They know the precautions are necessary to minimize the risk of infection in the patients they are operating on. 

I wonder how mask refusers would react if their surgeon wanted to perform major surgery on them without wearing a mask. Can you imagine the reaction if a surgeon said, “This is America and I am free to not wear a mask in surgery if I don’t feel like it!” Hopefully mask deniers would realize that would not be a good idea, but I’m not so sure they would.

Surgeons themselves were slow to adapt. In the not so “good old days,” they operated in street clothes with no gowns or gloves, and with unwashed hands. Sometimes the street clothes were visibly filthy or even blood-stained. When Ignaz Semmelweis (1818–1865) discovered that doctors had been causing puerperal fever, they refused to believe they were at fault. They had been going directly from autopsies to the wards, where they touched obstetrical patients, transmitting the deadly bacteria. No wonder they resisted Semmelweis: they didn’t believe in germs (the germ theory of disease wasn’t established until long after his death). Handwashing was shown to reduce mortality to less than 1%, but they refused to believe the evidence. A frustrated Semmelweis had a nervous breakdown and died in a mental institution.

Surgeons didn’t start consistently wearing gowns until 1901, caps until 1930, gloves until 1937, and masks until 1937. Today, no one in medicine is a mask denier. Not only because they have pledged an oath to “first, do no harm,” but also because they understand the principle of freedom: that the freedom for me to swing my fist ends at your nose. People should be free from other people’s germs where possible, and that is why masks and social distancing are advised.

Advice from the WHO

The World Health Organization (WHO) website has instructive videos showing how to wear a mask. They advise cleaning hands both before putting the mask on and after taking it off, not touching the mask, making sure it fits properly without gaps, and removing it by the ear loops while leaning forward and avoiding any contact with the front of the mask. They cover proper storage and cleaning of re-usable masks, and they remind viewers that the mask alone will not guarantee protection, and people must still follow social distancing and handwashing recommendations. They explain that prolonged use of masks does not cause CO2 intoxication or oxygen deficiency. This has been tested; despite the fears of some in the public, blood oxygen and CO2 levels are not affected by wearing masks. Masks should not be worn while exercising, because sweating can make the mask wet which can interfere with breathing and promote the growth of microorganisms.

The WHO also dispels a number of myths: the virus is not spread by house flies, mosquitos, or 5G networks. It can’t be cured or prevented by alcohol, bleach, adding pepper to your soup, sun exposure, hot weather, hot baths, cold weather, snow, hand dryers, garlic, rinsing the nose with saline, antibiotics, vaccines for flu or pneumonia, or any specific medications. UV lamps should not be used to disinfect the hands or skin.

Masks are effective

The Philadelphia Inquirer reported on June 24 that in the sixteen states that recommend but do not require wearing masks in public, new cases of Covid-19 had risen by 84% in the previous two weeks, while in the 11 states that mandated wearing masks in public, new cases had fallen by 25%. That’s only one data point, but it is consistent with information from other sources. It is inescapably true that masks do work to reduce the rate of transmission. The evidence is clear, no matter how much some people want to deny it.

It is difficult to get reliable data because of the variety of masks in use and the variations in the way they are used. Perhaps the greatest problem is that so many people wear them wrong. We see people with the mask pulled down to expose the nose, essentially wearing a “chin mask.” Since Covid-19 is not transmitted by chins, how could they expect that to do any good?  There are even people who must think the virus is transmitted via the Adam’s apple, since their masks only cover that area. We see people touching the outside of their masks, removing them to talk to others, touching their face and eyes, and entering close-packed crowds without wearing their masks. If people don’t use masks consistently and properly, the protection vanishes. Studies have counterintuitively found more virus on the outside of the mask, so it is particularly important to avoid touching that area.

A systematic review of 19 trials supported the benefits of community mask wearing by well individuals. Another systematic review and meta-analysis was published in The LancetIt reviewed 172 studies and found good evidence to support social distancing, wearing masks in public, contact tracing, and eye protection. They commented, “Face mask use could result in a large reduction in risk of infection.”

Countries that required masks early on had fewer cases. A new study, not yet peer-reviewed, looked at coronavirus mortality and death rates in 194 countries, and found that in countries where masks were mandated and culturally accepted, the per capita coronavirus mortality increased by 8% per week, compared to 54% per week in other countries where mask wearing was less prevalent. 

In an encouraging report, two Great Clips hairstylists who tested positive for Covid-19 and wore masks did not pass it on to any of their 140 customers.

Wearing masks in public is twice as effective as if masks are worn by everyone rather than only after symptoms appear. And “even homemade masks made from cotton t-shirts or dishcloths can prove 90% effective at preventing transmission.” 

A model developed by the University of Washington’s Institute of Health Metrics and Evaluation predicts that 33,000 fewer people will die by October 1 if 95% of the U.S. population wears masks in public spaces. 

Hierarchy of masks

A comparison of masks found that the N95 equivalent mask blocked more than 95 percent of all particles, as expected. The surgical mask was around 40 percent effective, with the dental masks coming in at around 60 percent. Cotton masks were around 30 percent effective and cotton handkerchiefs ranged from 2 percent (one layer) to 13 percent (four layers).

Mixed messages confused the public. Early advice to only use N95 masks when treating sick patients was based on the fact that personal protective devices were in short supply and should be reserved for those who needed them most. That is no longer true. When we learned that asymptomatic people could carry the virus and infect others, everyone was encouraged to wear masks not for their own benefit, but to protect others. And they do also provide some protection for the wearer.

How is the virus transmitted?

The coronavirus can last on metal surfaces for 5 days, on wood for 4 days, on plastics for 2-3 days, on stainless steel for 2-3 days, on cardboard for 24 hours, on copper for 4 hours, on aluminum for 2-8 hours, on glass and ceramics for up to 5 days, and on paper from minutes to days.  That doesn’t necessarily mean they will cause an infection, but it’s a good idea to regularly clean and disinfect common surfaces. Wearing a mask will not protect you from virus on surfaces, and it is not an excuse to slack off on hand washing.

As far as we know, no-one has gotten Covid-19 from food or drinking water. In restaurants and crowds, the risk is from other people, and it increases with the length of exposure. The risk is greatest for droplet transmission through the air, which can happen even when asymptomatic people don’t know they are infected.

Conspiracies and fallacies

Some of the arguments people make to justify mask refusal are almost comical.

A sheriff in Washington State pushed back against the governor’s mandate to wear masks, saying, “Don’t be a sheep. Why are people going and trying to take away our First Amendment rights?” You might be a sheep if you only wore a mask because you wanted to mimic what everyone else was doing; you are not a sheep if you wear a mask because you know it reduces transmission and you want to protect yourself and others.

The argument about taking away our First Amendment rights is common, but it is based on faulty reasoning. Here’s what the First Amendment actually says: “Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof; or abridging the freedom of speech, or of the press; or the right of the people peaceably to assemble, and to petition the Government for a redress of grievances.” In the coronavirus pandemic, no laws have been passed and no Constitutional rights have been infringed.

The need for quarantine in a disease outbreak emergency outweighs everything else. Typhoid Mary was forcibly quarantined, violating her right to freedom in order to keep her from transmitting typhoid to the people she cooked for. Citizens have rights, but they also have responsibilities. The right to drive doesn’t mean the right to disregard rules, drive recklessly, and endanger the lives of others. In a pandemic, citizens have a responsibility to follow public health guidelines designed to help prevent the spread of disease and unnecessary deaths.

Some have argued that the rules interfere with their right to worship; but they don’t. They only make it safer for people to attend religious services, and of course you can worship at home, with others via Zoom or Skype, or in churches practicing proper social distancing. Others say the rules will interfere with their right to vote, but that’s not true either. Most states have vote-by-mail options, and there’s no reason that practice couldn’t be extended to all states as a rational response to the pandemic.

One woman said she wouldn’t wear a mask for the same reason she doesn’t wear underwear: “things need to breathe.” No, your lungs need to breathe; your skin doesn’t. If she really believed what she says, why would she wear clothes at all?

Palm Beach County voted unanimously to require the use of face masks in public spaces, sparking an eruption of angry residents. 52 people testified, almost all against masks; and the video went viral. One woman said, “You literally cannot mandate somebody to wear a mask knowing that mask is killing people.” Masks don’t kill people. One can only wonder where that misinformation came from. If masks kill people, wouldn’t surgeons be dying like flies?

Some protestors called it “the devil’s law” and said people who follow it are going to be arrested. “They want to throw God’s wonderful breathing system out the door.” But of course, masks don’t do anything to interfere with the breathing system. The mask wearer breathes normally; all the mask does is filter out some of the infective droplets to protect other people. “Every single one of you is going to be punished by God. You can not escape God.”

Another woman compared the law to Nazi Germany’s treatment of the Jews: “we were forced to wear a gold star, told to get on a box car to be taken to a safe place…This is not about health, this is about submission.” They shared conspiracy theories about a “communist dictatorship” that is “brainwashing people.” The distancing requirement is “military protocol.” “You’re trying to get people trained so when the cameras, the 5G comes out, we gotta get scanned, we gotta get temperatured. Are you insane? All of you should be in a psych ward.” And, predictably, since he supposedly engineered the pandemic so that he can implant a chip into people’s bodies when they are eventually vaccinated, “Why is Bill Gates not in jail?”

 “Keep listening to the TV brainwashing you from birth.” There was talk of the Deep State and pedophiles. There was denial: “There’s not enough [COVID-19] to make it a pandemic.” They want to “put masks on your face to keep us from breathing oxygen, to get us to become sickly.” “I want to know who is getting paid off and where is the mandate coming from.” The comments were rife with vitriol but lacking in evidence. Meanwhile, Covid-19 cases in Florida increased to record levels.

History repeats

Mask resistance is nothing new. In the 1918 flu epidemic, masks were mandated. Most people complied, but many complained that masks were uncomfortable, and some even poked holes in them so they could smoke! Mayors and other prominent people were photographed not wearing masks. Communities that implemented stronger health measures overall fared better than those that didn’t.

Mask refusers sound like petulant children: “I don’t wanna wear a mask. You can’t make me. You’re not the boss of me.” When I see someone not wearing a mask, it says to me “I don’t care about other people. If you get sick and die, that’s not my problem.”

The bottom line

Steven Novella says we should all wear masks in public; but we should learn to wear them properly, and we should act as if the mask does not work. I couldn’t agree more!

This article was originally published in the Skeptic Reading Room.

Dr. Hall is a contributing editor to both Skeptic magazine and the Skeptical Inquirer. She is a weekly contributor to the Science-Based Medicine Blog and is one of its editors. She has also contributed to Quackwatch and to a number of other respected journals and publications. She is the author of Women Aren’t Supposed to Fly: The Memoirs of a Female Flight Surgeon and co-author of the textbook, Consumer Health: A Guide to Intelligent Decisions.

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