Philip Greenspun’s Weblog

… so they will definitely work in the general population.

“Universal Masking to Prevent SARS-CoV-2 Transmission—The Time Is Now” (JAMA) says masks worked in the hospital:

In the largest health care system in Massachusetts with more than 75 000 employees, in tandem with routine symptom screening and diagnostic testing of symptomatic HCWs for SARS-CoV-2 infection, leadership mandated a policy of universal masking for all HCWs as well as for all patients. The authors present data that prior to implementation of universal masking in late March 2020, new infections among HCWs with direct or indirect patient contact were increasing exponentially, from 0% to 21.3% (a mean increase of 1.16% per day). However, after the universal masking policy was in place, the proportion of symptomatic HCWs with positive test results steadily declined, from 14.7% to 11.5% (a mean decrease of 0.49% per day). Although not a randomized clinical trial, this study provides critically important data to emphasize that masking helps prevent transmission of SARS-CoV-2.

Therefore, masks will send coronaplague packing:

First, public health officials and leaders need to ensure that the public understands clearly when and how to wear cloth face coverings properly and continue building the evidence base for their effectiveness. Second, although cloth face coverings are generally well tolerated for short periods, with prolonged use they can be irritating or difficult for some people to breathe through, especially in hot or humid environments. Innovation is needed to extend their physical comfort and ease of use. Third, the public needs consistent, clear, and appealing messaging that normalizes community masking. At this critical juncture when COVID-19 is resurging, broad adoption of cloth face coverings is a civic duty, a small sacrifice reliant on a highly effective low-tech solution that can help turn the tide favorably in national and global efforts against COVID-19.

The apparent contradiction between the bold-faced portions is not addressed.

[Potential bad news for American Karens: “It is probably safe for individuals and safe for others to drive alone…without a face covering,” (see this instructional video)]

So… the Swedes and the World Health Organization (advice through early June) are wrong about masks for the general population being effective in reducing plague? How might we be disappointed a few months down the road if we rely on this article?

1. In a hospital people don’t have any real choice about how far apart to stand (similar to public transport). So the donning of masks won’t lead people to change their “social distance” (risk compensation and see also “Why is Sweden still not asking people to wear face masks?”).
2. Each hospital worker has been fitted for an N95 mask (choice of at least 6 different styles) by a professional fitter.
3. Hospital workers dispose of the masks between patients or at the end of each day. Hospital workers have access to handwashing and hand sanitizer within a step or two.

When you look at two members of the general public in a grocery store, none of the foregoing applies. Hospitals and doctors’ offices here in Maskachusetts seem to recognize this. If you need to enter one of these buildings you will be required to put your saliva-soaked face rag back into your pocket. Then you will be required to use hand sanitizer or soap and water. Then you will be given a brand-new clean paper face mask to wear. The bandana that protects society from the plague going exponential is not considered worthwhile protection inside the hospital.

Department of Sweden is still right (Karen Philip’s favorite department!): the Swedes give out free clean masks when people are getting on public transport.

Separately, if it as easy as the Mask Karens say to eliminate a virus by putting masks on the general population, why didn’t we use this technique to eliminate influenza, which has killed literally millions of Americans during my lifetime?

(What’s the downside of relying on masks? If we put our faith in masks and then, a few months down the road discover that they aren’t effective for the general population, that delays the measures that we actually need to take, e.g., moving more activities outdoors under shade structures, decluttering retail environments, having crowded high schools rent empty big box stores so that students can be spread out more.)

Bonus: allegorical photo showing the fate of those who don’t wear a mask, from the old fishing hamlet of Helgumannen. Faro, Gotland.

and another one… (Langhammars. Faro, Gotland)

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I recently spoke with two attorneys from Charlottesville, Virginia. They wanted to get tested for active coronaplague in preparation for a family reunion that included some older relatives. One is employed by the state and therefore both have absolutely top-of-the-line health insurance.

“Most of the places we called said that we couldn’t get a test unless we had symptoms,” said the wife. “We did finally find a place, but they said that the results wouldn’t be available for 8 days.”

Maybe things are better in Maskachusetts? Cambridge was offering free testing for residents and, by July 8, the entire month of July had been booked (i.e., the wait to get tested and then receive a result would be at least 25 days or so).

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Given what I have seen of mask usage in practice, I do not think they will be helpful in the U.S. except maybe to delay infections by a few weeks. I agree with the Swedes and the WHO that this is likely to be a multi-year experience with the coronavirus. And there will likely be another similar virus right behind this one. So I think we would slow down viral spread more effectively by restructuring our physical environment so that it isn’t relevant whether people are using a bandana improperly (or wearing a mask with an exhaust valve, which I see regularly among the righteous of Cambridge), etc. More stuff could happen outdoors under shade structures, for example.

I wonder if the mask is like Linus’s security blanket in Peanuts. People like to believe that they can control their fate. We hear that someone died of cancer and ask “Did he smoke?” The person is dead so it shouldn’t matter, but we want to know because we want to be assured that we won’t be killed by a random cancer and that we can extend our lives by clean living. The “science” as of March (and through early June at the WHO!) was that masks wouldn’t protect 8 billion humans from spreading coronavirus. But we didn’t like that answer so “science” gave us a new answer. It is highly comforting because we are controlling our fate, not living or dying depending on the whims of the virus and the accidents of geography (Maine versus Massachusetts, for example, a 14:1 difference in death rate).

Like most people, I hope that the universal mask laws can have some beneficial effect. But I fear that we are setting ourselves up for yet another disappointment and we will whip ourselves for not doing a good enough job. Yes, we wore masks, but too many of us did so without covering our noses. Yes, we wore masks, but that led too many of us to abandon the 6′ social distance. We wouldn’t have had a death rate comparable to Sweden’s if only we had…

This is kind of like the difference between Greek/Roman religion and Christianity. If the barbarians attack and burn your Greek/Roman city, you say “That was a terrible experience, but the gods are capricious sociopaths so we will just have to rebuild as best we can.” If the same thing happens to a Christian, he/she/ze/they must say “God is benevolent and omnipotent, so it must have been our wickedness that led to this bad outcome.”

I wonder if there is a mask experiment happening for us right now. Massachusetts and New York had a big surge in infections and then deaths back before any mask laws went into effect (May 6 here in what is now “Maskachusetts”). Florida and Texas have come out of shutdown. They are pretty well masked. We would expect the arc of the epidemics there to be less dramatic than in NY and MA due to (a) a bunch of restrictions still in place, e.g., no mass gatherings, (b) nursing homes much better protected than in MA or NY. But is the arc yet more attenuated in a way that we can perhaps attribute to Floridians and Texans being under mask orders?

Related:

• “Flu Masks Failed In 1918, But We Need Them Now” (HealthAffairs): In 1919, Wilfred Kellogg’s study for the California State Board of Health concluded that mask ordinances “applied forcibly to entire communities” did not decrease cases and deaths, as confirmed by comparisons of cities with widely divergent policies on masking. … Second, the review of practices in 1918 demonstrates masks must be worn correctly and consistently, fully covering the nose and mouth, with sufficient layers to prevent the spread of droplets. Advocates for masks in 2020 can use this historical lesson to argue that masks must be worn properly, or they will not achieve their objectives. [Summary: this time it is different and Americans will be as good at using masks as surgical nurses]

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A variety of U.S. airlines are going the full cattle car route, right? (see https://philip.greenspun.com/blog/2020/06/16/american-airlines-the-magic-of-air-travel-in-the-age-of-corona/ )

The theory is that the magic of masks will protect the 150 people on a 150-person Boeing or Airbus from giving each other the plague. (As a friend notes “If a bandana is effective PPE for Covid, then a saline injection is surely an effective vaccine.”)

Suppose that you’re on one of these Plague Special flights. The person sitting next to you is infected with coronavirus. You’re wearing a surgeon’s mask, which provides almost no protection for inhaling. Your infected neighbor removes his/her/zir/their bandana to drink some coffee or eat a sandwich. That’s not prohibited, right? Why don’t you get coronaplague during the 15 minutes that it takes your middle seat neighbor to eat/drink?

Suppose it is a six-hour coast-to-coast flight. Your exposure to your unmasked middle seat neighbor might be a full 30 minutes. Isn’t that long enough to transmit any virus?

Related:

• “Professor in microbiology, Hans Jørn Jepsen Kolmos, thinks that facial masks will be a solution to protect ourselves from the coronavirus on multiple segments of the journey. Just not on board the aircraft.”

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Florida is being described as a Covid-19 disaster zone, but I wonder if the state is being punished for its own success at the March 2020 dogma of Flatten the Curve. Here’s a chart of tests performed and percent positives from John Hopkins:

Florida’s governor ordered a shut down effective April 3. The state began reopening in May. Can we infer from the above data that Florida, with its dense linear city, was a natural plague center, but the dramatic suffering and efforts of citizens actually had a huge effect? From mid-April to mid-June, only a small percentage of Floridians who sought a plague test actually came up positive.

Let’s look at Massachusetts for contrast:

Essentially a textbook unmitigated infectious disease epidemic, right? How about New York?

So… Florida is being pilloried despite the fact that it actually might be one of the most successful examples of flattening the curve!

(Of course, just as noted by the former chief scientist of the European CDC, and just as promised by Flatten the Curve advocates here in the U.S., infections were merely delayed by this success, not prevented. So the current state of Covid-19 affairs in Florida is exactly what one would expect given the successful shutdown.)

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