When the novel coronavirus started to get stroppy and make its now global impression, one theme seemed to be common. Facemasks were, at least initially, a conceit, a sort of fashion or extra-medical accessory. To use it was a mark of vanity. Rushing out to stock up on such masks was also selfish: you were taking them from the medical profession who needed it more than you.
From vanity and selfishness, masking up has become a necessity. Whole countries have been given the spanking of a lockdown, with consequential economic contractions. With the details of opening up and easing restrictions being put to paper, the collective, public use of facemasks is being encouraged and, in some cases, mandated.
Many of Germany’s federal regions have made wearing masks mandatory on public transport and when shopping, though the regulations vary. Austria has decided to make them compulsory when shopping. But confusion and inconsistency reigns in some quarters. Prime Minister Winfried Kretschmann of Baden-Württemberg has suggested the use of scarves and cloth covers for the general citizenry while reserving medical masks for health workers.
Kretschmann’s qualification revisits old concerns about hogging the necessary equipment and taking from the health warriors who are engaged in the battle. This is a concern facing those in Britain’s National Health Service. Will such encouragement incite a stampede that will outstrip supply?
The science behind wearing a mask remains a question of dispute. Then again, much of the policy weapons deployed against COVID-19 could be bracketed that way. Hilda Bastian spouts irritably in Wired against the “double standard” on wearing face masks, which receive a scholarly, hyper-rigorous attentiveness. “We don’t see op-eds that ask whether people really need to keep 6 feet away from each other on the street, as opposed to 3 feet, or that cast doubt on whether it’s such a good idea to promote bouts of handwashing that are 20 seconds long.” Infectious diseases consultant Babak Javid says much the same thing, claiming that the results from laboratory tests on handwashing are, at best, disappointing, while there have been none to speak of regarding physical distancing.
The trials on facemasks have, for the most part, been unrewarding in their results. There are issues about adherence, problems about whether the masks are even worn properly and even whether wearing such masks conveys a false sense of security. Consider, for instance, a recent letter of waning by ear, nose and throat surgeon Guy A. Vernham to the editor of the BMJ. “I would argue that incorrect mask wearing in particular, is a serious concern which might result in an increased risk of spread: Incorrect fitting and removal, failure to understand associated hand hygiene and touching/adjusting the mask during use do run a risk of contagion which could outweigh any benefits.”
When teased out, the existing complement of trials suffer from methodological pitfalls. A US study examining 1437 young adults in university residence halls during the 2006-7 influenza season found that the use of facemasks and an attentiveness to hand hygiene “may reduce respiratory illnesses in shared living settings and mitigate the impact of the influenza A(H1N1) pandemic.” Despite this effort being commended, the findings had to be seen in light of the following: that the trial took place during a mild flu season; there was a chance that some students were infected prior to the trial’s commencement; and the study was not designed, according to Titus L. Daniels and Thomas R. Talbot, “to detect small differences that may be demonstrated by the incremental use of face masks to hand hygiene”.
Reviews on the published studies throw up similar methodological problems. A survey of 31 eligible studies, including 12 randomised controlled trials (RCTs) on the use of facemasks, found that the latter “often suffered from poor compliance and controls”. Such RCTs were expected “to under-estimate the protective effect” of the masks, with observational studies having an opposite, exaggerating effect. Participants who were tasked with wearing masks often did not; those who should not have, did.
According to Julii Brainard, a senior researcher in modelling public health threats, “Part of the reason why the research has been so difficult is that what should be our best-quality experiments aren’t very good. So we’re stuck with what are called observational studies where researchers ask what people did.”
The argument for facemasks has now pivoted away from the healthy wearer who is concerned about infection; the current focus is on the one who is already infected, exhibiting asymptomatic or mild symptoms. This chimes with the message that you are doing your bit to prevent transmission, while injecting a moral sting into matters. And if all else fails to convince, the precautionary principle – that such masks be worn, according to a study in the BMJ, “on the grounds that we have little to lose and potentially something to gain from this measure”, comes into play.
As with much in the realm of public health, policy is often made on the hop, done to cope with panic and calm troubled waters. With interest now on returning some blood into the arterial streams of the global economy, the scientific equivocality behind the length of time one washes hands to the nature of mask one wears, will take second place to the expediency of reassurance.