By now, we are all well familiar with the fickle vacillation of public health guidance around community masking. Initially, masks were simply not really effective. Shortly thereafter, they were not only effective for protecting others, but also for protecting oneself. Then they were mandated. Most recently, those cloth masks that have become commonplace, which were encouragedfor nearly two years, which we were taught to hand-make by news outlets, were suddenly, as if overnight, relegated to ‘facial decorations.’
How can it be that a tool which has been around and studied1 for well over 100 years in the context of aerosolized respiratory viruses suddenly seems so poorly understood? This mini-review will advance the argument that low-quality evidence and impoverished bioethical frameworks have informed a deeply fraught relationship to masking in America.
While we have surely all heard some variation of the argument that Americans are too myopic or selfish to do what people in Asian countries have been doing for decades, this is insufficient for making sense of the present moment. Ignoring the knowledge we have, avoiding cost-benefit analyses, and most importantly failing to clarify fundamental ethical principles risk irreversibly damaging the credibility of medicine and public health in the eyes of those we wish to serve.
Influenza-Based Studies of Face Mask Efficacy
It is crucial to understand pre-COVID-19 research on mask efficacy in the context of influenza because, as was recognized early on, both respiratory pathogens are thought to be able to spread by breathing alone via exhaled aerosolized particles.2 Prior to the COVID-19 pandemic, as late as 2019, the WHO Global Influenza Programme published an analysis of nonpharmaceutical interventions (NPIs) in the context of a potentially deadly viral respiratory pandemic,3 at the time considered most likely to result from a novel influenza strain.
Culling systematic reviews of 18 NPIs including respiratory etiquette and face masks, the authors concluded that “[t]here is…a lack of evidence for the effectiveness of improved respiratory etiquette and the use of face masks in community settings during influenza epidemics and pandemics.” Nonetheless, the authors acknowledge that while “[t]here have been a number of high-quality randomized controlled trials (RCTs) demonstrating that personal protective measures such as hand hygiene and face masks have, at best, a small effect on influenza transmission, … higher compliance in a severe pandemic might improve effectiveness.”
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See Also:
(1) What an Honest Vaccine Rollout Announcement Might Have Looked Like
