At the beginning of the coronavirus pandemic — before it was called a pandemic — the advice from U.S. public health officials was clear: If you aren’t sick, you don’t need to wear a mask.
The national discussion about mask-wearing has since become more ambiguous. The public health advice remains the same, but critics say the guidance was wrong and confusing and may have encouraged mask-hoarding.
There’s a #masks4all movement on social media that argues for universal mask-wearing amid the pandemic, with some proponents saying it shows community solidarity in the fight against coronavirus.
On Tuesday, Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, said the White House coronavirus task force will be “seriously considering” broader recommendations on mask-wearing for the American public once there’s an adequate supply for health care workers.
Also, on Tuesday, health officials in California’s Riverside County issued a recommendation that all county residents cover their nose and mouth for essential travel to doctor’s appointments, grocery store and pharmacy visits. The face coverings do not need to be medical grade, the county said.
On Wednesday morning, U.S. Surgeon General Jerome Adams said the U.S. Centers for Disease Control and Prevention had been asked to review its guidance on wearing masks.
Some proponents of universal masks are citing the recent case of a choir in Washington state, where members appear to have contracted the virus through the air via an asymptomatic person or people. The Los Angeles Times reported this week that 45 of 60 members who showed up for one practice later tested positive for the new coronavirus. Two are dead. Eight attendees told the Times that no one was coughing or sneezing, and that they practiced social distancing.
In an article published Friday in Science Magazine, the director-general of the Chinese Center for Disease Control and Prevention said the biggest mistake Americans and many European countries are making in fighting the new coronavirus, which causes COVID-19, is that they aren’t wearing masks.
The issue is giving rise to public debate. There are still many health experts who maintain the public does not need to wear surgical masks, as people in some other countries like China do, and that in some cases, it could give people a false sense of security.
Some public health experts say wearing a face mask actually causes people to touch their face more, which is bad for spreading the virus.
“I’m on the side that the general public should not be wearing masks as a general rule,” said microbiologist Kelly Reynolds, a professor at the University of Arizona’s Mel and Enid Zuckerman College of Public Health. “The data just does not support that it’s effective in a broad population.”
One of the problems with having a universal mask-wearing public is that they could be wearing the mask for a prolonged period of time, Reynolds said, and increase rather than decrease their chances of getting exposed to the virus. The mask itself may become a virus-collecting source of infection.
“What they are actually doing is concentrating the virus on the mask over time,” she said. “You could be exposing yourself inadvertently.”
But the message to the public is confusing: You don’t need a surgical mask, but health care workers do.
The reason for that is health care workers don’t have the advantage of social distancing, said Dr. Rebecca Sunenshine, medical director of disease control for the Maricopa County Department of Public Health.
“We have health care workers out there on the front lines who need these masks to protect them while they have to stand right in front of people who are actively coughing and sneezing and very, very sick,” she said. “They have to care for them and they don’t have the option of standing six feet away from them. And we would like to preserve those masks for health care workers. That is part of living in a community where the people who are at the highest risk of getting exposed need to have the protection.”
If there was an unlimited supply of masks, Sunenshine said she personally would still not choose to wear one in public.
“My daughter, who has asthma — I would not have her wear a mask in public,” Sunenshine said. “I don’t think that the benefits outweigh the discomfort and the possibility that it would get contaminated. But that is my personal recommendation for myself and my family.”
The U.S. Centers for Disease Control and Prevention’s recommendation on masks is to wear a face mask if you are sick when you are around other people. If you are not sick, the CDC says a face mask is only needed if you are caring for someone who is sick, and they are not able to wear a face mask.
“Face masks may be in short supply and they should be saved for caregivers,” the CDC advice says.
Critics are starting to question that guidance, saying public health recommendations should not be taking mask supply into account.
An opinion column published March 28 in the Washington Post by University of San Francisco research scientist Jeremy Howard has become a talking point on television news shows and in print publications across the country. Howard argues that public health advice against mask-wearing was a policy misstep that needs a course correction.
“Masks effective at ‘flattening the curve’ can be made at home with nothing more than a T-shirt and a pair of scissors,” he wrote. “We should all wear masks — store-bought or homemade — whenever we’re out in public.”
In an email exchange with The Arizona Republic, Howard said the feedback he’s been getting since Saturday has been “98% supportive.” Some doctors have suggested that the science is unclear, but Howard disputes that claim. The science is clear, said Howard, who is the founding researcher at fast.ai, a data-focused research institute.
His Washington Post piece says he found 34 scientific papers indicating basic masks can be effective in reducing virus transmission in public. He also said he found not a single paper that shows clear evidence that they cannot.
Saskia Popescu, a senior infection prevention epidemiologist at George Mason University, says DIY masks offer some “quite limited” protection, but they are easily soiled and need constant cleaning. She has found the literature on community-wide mask usage also limited, with both pros and cons.
“Surgical masks are not perfect in that they don’t fully seal around the face and are only one piece to infection prevention efforts,” she wrote in an email. “Most people don’t realize how easy it is to cross-contaminate when wearing a mask and frankly, wear them incorrectly. ”
She also said universal mask-wearing could lead sick people to think a mask is acceptable protection.
“You should be staying home if you’re sick,” she wrote.
Reynolds, the UA microbiologist, says if the public did wear masks, they’d need to be educated in how to put them on and take them off — a process that in the health world is called “donning” and “doffing.”
“I haven’t done studies with the general public. But I have done studies with health care workers. They don’t always take the masks off properly,” she said.
“About 30% of the people we worked with were making mistakes with their PPE (personal protective equipment). That could be gloves or masks or gowns. Overall, we saw mistakes where they touched the mask in a place that could contaminate their hands.”
When “doffing” surgical mask, it’s important to use the elastic straps without ever touching the front of the mask, Reynolds said. Even some health care workers, she said, have a habit of just grabbing the mask from the front, pulling it away from their face and stretching it over their head, which could contaminate their hands with what might have concentrated on the mask.
“It could also, in the action of moving the mask around, aerosolize the viruses that were concentrated on the mask and expose you even more,” she said. “We see so many mistakes with people who are even trained to do this.”
The #masks4all proponents such as Howard emphasize that masks are not a substitution for good hand hygiene, isolation, quarantine, contact tracing and social distancing.
But he says the argument that the public could inadvertently contaminate their mask is “spurious” because it’s better for the mask to be contaminated than the person wearing it.
Telling people they won’t know how to properly wear a mask “isn’t a winning message” and is “deeply counterproductive,” Zeynep Tufekci, a University of North Carolina associate professor of information science, wrote in a New York Times op-ed.
“Many people also wash their hands wrong, but we don’t respond to that by telling them not to bother. Instead, we provide instructions; we post signs in bathrooms; we help people sing songs that time their handwashing,” she wrote.
Tufekci said that messaging about the scarcity of masks and the need to preserve them for health care workers may have led members of the public to hoard them.
As for Howard’s advice that a T-shirt or bandana could be used to make a mask, a point that he made in his Washington Post column, the UA’s Reynolds is skeptical.
“Now we have a mask that is not designed to remove anything in particular,” she said. “For somebody to select that now, when you are not even being exposed to a patient, that makes no sense to me. If you social distance, you will avoid the large droplet exposures much better than if you wear any kind of mask.”
Sunenshine of the Maricopa County Department of Public Health said she always has been transparent about why it’s not recommended that members of the general public wear masks unless they are sick or caring for someone in their home who is sick and can’t wear a mask.
First, it can cause more harm than good, she said, and, second, it could take away resources from health care workers who need them.
Sunenshine said she’s not an expert in homemade masks yet understands that for some people, it could help lower anxiety, and that could be helpful. The wearer needs to be aware the mask could get contaminated, she said.
Some other reminders for the wearer of a homemade mask: It needs to be made in a way that prevents secretions from getting inside, it needs to be washed regularly, and the wearer should be mindful about not touching the mask. If they do touch the mask, they need to wash their hands, she said.
It is not yet determined whether or not the public should be wearing masks, but hand washing, and social distancing are the main keys to stopping the spread of COVID-19.