To don or not to don a mask?

This article is written by Cory Schlievert, Senior Strategist, Nova Scotia Department of Health and Wellness and Apolitical Insider Fellow. This article was edited by Charlotte Sullivan, Policy Analyst at Immigration, Refugees and Citizenship Canada and Apolitical Insider Fellow.

To mask or not to mask against Covid-19 has been much debated.

China, the first country to experience the outbreak in January, opted to treat the disease as a level A disease risk (e.g. plague, cholera) and adopted the most protective personal equipment despite officially categorising it as a level B disease (e.g. strep throat, influenza). For months, the World Health Organization (WHO) had advised against the public’s use of masks for lack of evidence, with some senior health officials suggesting it may even cause more harm than good.

Recently, WHO shifted its advice for the public to don a cloth mask when physical distancing is not possible. It’s hard to understand motives for downplaying the transmission risk of Covid-19 instead of taking a more prudent approach, as China had, to protect against the unknown disease. Isn’t it better to be safe than sorry?

The sneeze that’s heard around the world

Up until now, many public health experts had touted that wearing masks may provide a false sense of security and could even increase the spread of disease by increasing face touching from adjusting donned masks. WHO’s original stance was to reserve mask supplies for frontline health workers and the sick. While WHO maintains that surgical masks and respirators should be reserved for these groups, it has recently conceded to include cloth masks for the public in its advice.

It’s hard to ignore the petri dishes of cruise ships, air flights and long-term care homes. The disease seems so transmissible that it’s hard to feel confident that good hand hygiene and physical distancing are enough, and indeed it seems that now there is enough evidence to suggest that it is not. A cough or sneeze spreads germs in droplets a fair distance through the air, mingling airborne for a few minutes before settling. Not surprisingly, wearing a mask constricts and slows the spread of droplets caused by coughing or sneezing.

Different types of masks provide different levels of protection. A homemade cloth mask slows the spread of germs, reducing the chance of infecting others. Surgical masks and respirators offer increased levels of protection and in many countries have been reserved for health workers due to limited supply.

A new norm

The fact that certain countries downplayed the need for masks may have been for procurement-related reasons rather than for protection-related reasons.

It would be futile to issue a mask directive without a ready supply. In January, China, the primary global mask supplier, had also become the primary consumer, using so many masks that other countries sent masks to China in aid. Considering the supply required to meet global demand, the public health directive to downplay the risk at that time may have been driven by the hope of ensuring access for all countries by discouraging protectionist measures and reserving supplies for health workers. Despite those efforts, many countries implemented protectionist measures and even more mobilized domestic production. With domestic production of masks on the rise, WHO chose now — a time of civil unrest and mass protest — as the time to direct widespread donning of masks.

For many countries, wearing a mask is already common practice to protect against air pollution and perhaps increase privacy amidst modern public surveillance and facial recognition tactics. Taiwan’s successful Covid-19 response is largely attributed to its public’s quick mask uptake, effectively reducing symptomatic and asymptomatic spread, a response primed by its SARS epidemic in 2003. Now, donning a mask may become the new normal in more countries for the altruistic reason of containing germs from spreading to others.

As economies re-open, many essential workers — such as bus drivers, daycare workers and police officers — will be supplied with surgical masks for their regular day-to-day work where physical distancing is impossible. These core workers will model a new protective health standard that is visually impossible to ignore; applying social pressure on the collective to embrace donning a mask and potentially stigmatising those who do not.

Smiling through the mask

Disease outbreaks and adherence to public health measures (i.e. self-isolation, quarantine, physical distancing) have psychosocial consequences, and donning masks will as well.  Facial visibility is so relevant for social connectivity. The social consequences of donning masks differentially impact various populations, for examples for long-term care residents and people who are deaf or hard of hearing. Some astute childcare centres are selecting clear masks to meet the public directive but also ensure children can respond to facial signals and foster relationships with their caregivers for normal child development.

WHO takes many factors into account when advising the world: it considers economic and social impacts on global health as well as direct public health threats like Covid-19. Its actions over the course of this pandemic will be largely scrutinised, including its evolving mask directive, which confused the world and may have discouraged uptake. WHO’s credibility has been tested and judgements will be made as to whether the ends justified its means. Countries should consider adopting mask policies but should also consider the impacts of implementation strategies (e.g. laws, fines, education, messaging) on multiple facets of society (e.g. biopsychosocial, environmental, economic). — Cory Schlievert

(Picture credit: Unsplash)