Face masks and Covid-19: communal not individual relevance

One of the starkest differences between East Asian and European/North American responses to the Covid-19 pandemic has been in their differing attitudes towards face masks (used here generically, and differentiated from FFP3, also known as N95, respirators) : they are common in East Asian countries such as China, South Korea, Singapore and Japan, and yet are rarely to be seen in other parts of the world.  They have been part of the package of solutions recommended in East Asia, where infection and mortality rates have generally been quite low; yet they are absent in Europe and North America where rates are much higher.

World Health Organisation advice, followed assiduously by European governments and the U.S. Centers for Disease Control and Prevention (CDC) is clear:

• If you are healthy, you only need to wear a mask if you are taking care of a person with suspected 2019-nCoV infection.
• Wear a mask if you are coughing or sneezing.
• Masks are effective only when used in combination with frequent hand-cleaning with alcohol-based hand rub or soap and water.
• If you wear a mask, then you must know how to use it and dispose of it properly.

This is frequently interepreted in an abbreviated form, as by the BBC, to imply that “Only two types of people should wear masks: those who are sick and show symptoms, and those who are caring for people who are suspected to have the coronavirus”.

The case against wearing face masks comes down essentially to the argument that they will do little to protect someone from getting infected.  This is fundamentally an individualistic argument: “If I wear a mask it won’t be much good to me”.  However, from a communal perspective that is absolutely not the point; what matters is that if you wear a mask and are unknowingly infected it may help to prevent you spreading the infection to many other people.  Wearing a mask is about others not yourself.

A growing body of evidence is now suggesting that masks can indeed help to slow the spread of Covid-19:

• The markedly different histories of infection between countries where masks are encouraged/enforced as part of a package of measures, and those where they are discouraged, is forcing researchers and policy makers to try to explain why.  Masks are an obvious possible answer.
• It is increasingly being suggested that many Covid-19 carriers are asymptomatic.  They therefore don’t know that they might infect people, and so are going about their daily lives doing just that.  If they had been wearing masks, it is argued, this could reduce the number of people that they infect.
• Dentists and healthcare workers in many parts of the world are encouraged or required to use masks both to provide some protection from patients, but also to protect patients from any infections that a dentist may have.  If such masks are seen to be offering patients some protection, then it seems strange to suggest that they offer no protection against a coronavirus such as Covid-19 (see reviews of surgical masks and N95 masks by Loeb et al., 2009, and more recently by Long et al., 2020)
• Chinese doctors and scientists are increasingly confident that masks do make a difference.  In a recent interview, George Gao (Head of the Chinese Center for Disease Control and Prevention) has thus suggested that “The big mistake in the U.S. and Europe, in my opinion, is that people aren’t wearing masks. This virus is transmitted by droplets and close contact. Droplets play a very important role—you’ve got to wear a mask, because when you speak, there are always droplets coming out of your mouth. Many people have asymptomatic or presymptomatic infections. If they are wearing face masks, it can prevent droplets that carry the virus from escaping and infecting others”.

In societies such as the USA and much of Europe where the focus tends to be more on the “self” rather than the “community” it is scarcely surprising that individuals and their politicians see little value in masks; but in more communal societies, where there is  perhaps more care for others, then masks are seen as an important part of the armour against Covid-19.

Many governments fear that encouraging citizens to wear face masks would mean that there would be insufficient left for medical professionals to wear.   This, however, is rather a lame excuse.  Such governments could readily have put in place systems in early February to prepare to expand production of protective clothing.  It is not too late for them urgently to do so.  The BBC thus reports that “UK clothes makers say the government has wasted time in ordering personal protective equipment for NHS staff.  Fashion and textile firms believe they could have begun making gowns and masks for front-line workers 10 days ago”.

However, for those who do care about their neighbours and don’t want to disrupt the official production of masks for healthcare providers, an increasing amount of guidance is now available for making your own masks, as at:

• Business Insider: Kelly Burch on “How to make an effective face mask at home“
• Good Housekeeping: Lexis Sachs on “How to Make Face Masks for Hospitals During the Coronavirus Shortage“
• Smart Air: “What Are The Best Materials for Making DIY Masks?”

These are clearly not going to be as good as masks made by companies to stringent regulatory standards (for UK see Regulatory status of equipment being used to help prevent coronavirus (COVID-19)), but they may well offer at least some protection to reduce the communal spread of Covid-19.  Pressure on demand is likely to become very much worse than it is at present, especially when imported masks are low in supply and often fail to satisfy these standards: recent reports (see for example Business Insider, 29th March) thus suggest that 600,000 masks imported from China have had to be recalled by the Dutch government because they are faulty.  In countries unable even to import masks from elsewhere, domestic production in line with international standards (see Wong, A. and Wilkinson, A., 2020) can be recommended.

Above all, the discussion should not so much be about “will I be protected?” but instead “how can I protect others?“.  It rather depends on what kind of society we wish to live in – especially for those who are left after this pandemic has run its course.

[Update 30th March – it is great to see that Austria has announced today, the day after I wrote the above, that it is to make wearing masks compulsory, and will distribute basic masks for free at the entrances to all supermarkets]

[Update 31st March – Tom Whipple in The Times notes comments from Prof Cheng at Birmingham University and Prof Cowling at University of Hong Kong in favour of wearing masks, although Prof McNally, also from Birmingham, expressed concern that this would be counterproductive since people would think they could still go out]

[Update 2nd April – David Shukman on the BBC News site: Coronavirus: Expert panel to assess face mask use by public.  The WHO should have acted much more quickly on changing its advice]

[Update 7th April – Link to Lydia Bourouiba’s important study on turbulent gas clouds and respiratory pathogen emission: coughs and sneezes can spread #Covid19 7-8 m; CDC guidance is only 2 m; masks might help https://jamanetwork.com/journals/jama/fullarticle/2763852. We really need to rethink social distancing…]

[Update 7th July – BBC Coronavirus: Don’t leave home without a face covering, says science body – why has it taken so long for people in the UK to argue vociferously for this?]

[Update 15th December – Scientists say masks could stop coronavirus spreading in busy streets – nothing much has changed, apart from many thousands having died unnecessarily!  Just goes to show what an individualistic and selfish society we live in – as many of us have said for months, masks can help protect other people.  Every life saved matters]