Quebec and the rest of North America were ravaged by the plague in 2020. The USA floundered due to the nation’s struggle with pathological individualism in the presence of a self-absorbed national leader who thought himself smarter than those who’ve studied epidemiology for decades. Masks work, and always have worked.
The plague of anti-mask sentiment
Canadians could be doing much better in their efforts against the virus, but once again we only need look south to see how awful SARS-CoV-2 apathy can become. Whether it be through indoctrination, willful ignorance, or spite, a minority of North American citizens chose to aid the virus in its goal by becoming anti-maskers. This crusade against fellow citizens and healthcare infrastructure has led to the mask wars. Some anti-maskers even welcome misery, including malicious actors at the highest levels.
Because it’s essentially the only point they can make, anti-maskers are fond of reminding us about the high COVID-19 survival rate. This is one variable in a complex equation, but it also serves as a red herring. Unbeknownst to many, the catastrophic ripple effects of overburdened healthcare systems are real. At the time of this post (the final week of 2020), predictions about January as the worst month yet in North America are very likely to come true. And we can thank anti-mask sentiment for contributing so mightily to this human misery.
This graph shows weekly confirmed COVID-19 deaths in North American nations and the United Kingdom from the first day of summer through the first day of winter in 2020. On Dec. 27, the numbers over the previous week were as follows: USA 15,450; Mexico 4,224; UK 3,357; Canada 684. Obviously Canada has far fewer inhabitants, so in a more useful measure we can compare Canada’s ~40 deaths per 100,000 versus the USA’s ~102 deaths per 100,000 population (Dec. 28 data). Not only is Canada clearly doing better per capita, there’s also reason to believe underreporting of COVID-19 mortality in the USA.
The Hazard Lie
When #MedicalConservative physician John Mandrola innocently replied to someone on Twitter with “Does literally anybody think a mask is hazardous?”, he found out that yes, plenty actually do. Let’s quickly dispel the myth of physiological harm due to masks. Five physicians in Miami conducted a trial of 15 healthy individuals and 15 veterans with severe COPD. All wore surgical masks during the collection of end-tidal carbon dioxide and oxygen saturation data. The COPD group “did not exhibit major physiologic changes in gas exchange measurements after the 6-minute walk test using a surgical mask, particularly in carbon dioxide retention.”
These results build upon findings from a 2012 study of no clinically significant physiological impact or significant subjective perceptions of exertion or heat in 20 healthy volunteers who wore a surgical mask during an hour of a low-moderate work rate. We do know that many people feel discomfort while wearing a mask, which can be due to neurological reactions from the increased temperature of inspired air, or psychological issues such as “anxiety, claustrophobia or affective responses to perceived difficulty in breathing”. While these phenomena may occur, they do not point to masks being physiologically hazardous.
The Totality of Evidence
Below is a sample of research providing evidence for why wearing masks (in appropriate situations) is a good idea during this plague. Many dozens more supportive studies / papers can be found in scientific databases like PubMed. If you know an anti-masker who isn’t immune to science, go ahead and share a link to this post since we in turn present PubMed links to the papers discussed. Anti-maskers may offer you their own links to promote the anti-mask (pro-virus) agenda, but we regularly see only a half dozen or so studies / scientific papers that will support their view.
In science we rely on the totality of evidence to draw conclusions. And quelle surprise, the totality of evidence illustrates how masks work (and always have).
Knowledge Timeline
2008
Professional and Home-Made Face Masks Reduce Exposure to Respiratory Infections among the General Population
Unbeknownst to most North Americans, the 2002–2004 SARS epidemic in Asia led many governments to more seriously consider the widespread use of face masks as part of their public health preparedness plans. We could go back in time farther, but the earliest paper cited in this post review is this one, published in 2008. In it, three types of masks were compared for their transmission reduction potential: personal respirators, surgical masks, and homemade masks.*
The take-home message of this study was that although a high degree of individual variation in exposure protection was seen (due to behavioral and anatomical variables), any type of mask usage can decrease viral transmission. This was the earliest paper we saw in which it was suggested that the imperfect or modest effectiveness of homemade masks can be a benefit insofar as they “might sufficiently reduce viral exposure to impact on transmission during the early waves, while allowing people enough exposure to start mounting an efficient immune response.”
* Personal respirators are designed to fit to the face with as tight a seal as possible; they are designed to protect the wearer rather than the infected individual. Surgical masks are looser, as they’re primarily donned to protect others from the respiratory droplets produced by the wearer. (The lay public knows surgical masks as those now ubiquitous light blue “single-use” masks). Homemade masks are made of variable materials and are likely to be even looser than surgical masks.
2020 — Masks work and always have
April 2020
Aerosol Filtration Efficiency of Common Fabrics Used in Respiratory Cloth Masks
Remember back in April when we were all trying to figure out what types of masks work best, given circumstances? In this experiment the researchers had three objectives:
1— Test the performance of various fabrics against different particle size ranges (including the 10 nanometer to 5 micrometer scale for aerosols, which is particularly relevant for respiratory virus transmission).
2— Test “the effect of hybrid multilayer approaches for masks that can combine the benefits of different filtering mechanisms across different aerosol size ranges”.
3— Cover the topic of fitting a mask properly.
A take-home message from the study was that “combinations of various commonly available fabrics used in cloth masks can potentially provide significant protection against the transmission of aerosol particles”. Not surprisingly, the data also showed that properly fitted masks work much, much better — so make sure you take this into account in your own life! Here are some specifics:
May 2020
The subheading of this perspective paper doesn’t mince words:
The first in vivo evidence that surgical masks can prevent COVID-19 transmission
In May, we finally saw published experimental data on how masks helped animals avoid catching the exact virus most of us are trying to avoid (SARS-CoV-2). Animals wearing masks may sound a little silly, but in vivo research usually precedes studies in humans, and we ought not be so conceited that we forget Homo sapiens are classified as a member of the Animalia kingdom in taxonomy.
Medical mask versus cotton mask for preventing respiratory droplet transmission in micro environments
Taiwan did as well as can be hoped in countering the historic first wave of the epidemic. In this experiment, Taiwanese researchers found that cotton masks should be considered as a substitute for medical masks when trying to prevent a respiratory infection in microenvironments (like in a car) with air conditioning.
However, it should be emphasized that the filtration effectiveness of cloth masks varies widely depending mostly upon the materials used and the design of the mask. Australian researchers CR MacIntyre & AA Chughtai have over the years written about the filtration effectiveness of cloth masks. Anti-maskers, if they bother to cite anyone, sometimes cherry-pick work done by these authors while completely ignoring the broader and most recent conclusions by these same authors.*
* Towards the end of our post, we will discuss this tactic further.
June 2020
Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19
The first day of June saw publication of a meta-analysis of 44 comparative studies within a massive systematic review of 172 observational studies on COVID-19, SARS, and MERS from 21 databases / resources. At the time of its publication this study provided the best available evidence that physical distancing of 1 meter was associated with a large reduction in infection and that social distancing of 2 meters might be more effective. Additionally, the meta-analysis found that health-care workers and the general public benefit from face masks.
Community Use Of Face Masks And COVID-19: Evidence From A Natural Experiment Of State Mandates In The US
Anti-maskers attacked public health by demanding “proof” that masks work. Although it wouldn’t be surprising to find that 95% of anti-maskers are scientifically illiterate, it’s quite easy for them to redistribute the propaganda posted by committed anti-maskers who’ve cherry-picked data to promote a hatred of public health, an apathy towards the plight of hospitals, and a denial of reality. But legitimate concerns surely existed, including the “limited direct empirical evidence available on the magnitude of the effects of widespread face mask use in public on COVID-19 mitigation”.
June 16 saw the publication of findings providing “direct evidence on the effectiveness of widespread community use of face masks from a natural experiment that evaluated the effects of state government mandates in the US for face mask use in public on COVID-19 spread.” Anti-maskers quickly tried to discredit the study online, but we know that nearly all of them would never accept any amount of evidence that conflicts with their beliefs.
SARS-CoV-2 Infections and Serologic Responses from a Sample of U.S. Navy Service Members
Especially if you are trying to convince veterans or active service Americans, try appealing to a sense of patriotism by using this data from sailors aboard the aircraft carrier USS Theodore Roosevelt. The lower infection rate seen from mask use in this shipboard environment presents obvious benefits for military units during this public health crisis.
July 2020
Absence of Apparent Transmission of SARS-CoV-2 from Two Stylists After Exposure at a Hair Salon with a Universal Face Covering Policy
Findings from a small study published in July were remarkable enough to make headlines. Elegant in its simplicity, the results simply demonstrated that masks work. Infected hair stylists wearing masks did not transmit this highly contagious virus to their mask-wearing clients.
September 2020
Efficacy of masks and face coverings in controlling outward aerosol particle emission from expiratory activities
Going into autumn we saw the publication of an experiment where researchers tested 6 types of masks worn by healthy individuals to determine differences among mask types in reducing aerosol particle emission rates from breathing, speaking, and coughing. The researchers only measured one type of airflow (the physical dynamics of outward aerosol particle emission), but their results greatly added to the totality of evidence in assessing the utility of masks.
A take-home message is that surgical masks remain a preferred option for the public. The unvented KN95 respirator was slightly inferior, but importantly, fit-testing was not performed since the researchers wanted to obtain results most pertinent to the public (i.e., untrained individuals without access to professional fitting assistance). The homemade t-shirt masks were worse than useless, which reminds us of earlier studies (like some cited above) where we saw the importance of choosing the proper material and design if we don’t have access to surgical masks.
October 2020
Effectiveness of Face Masks in Preventing Airborne Transmission of SARS-CoV-2
Here’s a recent study with results modeling the effectiveness of masks. The researchers included a photo and detailed diagram of their airborne transmission simulator. A benefit of such a system is the ability to test varying amounts of exhaled virus.
Association of Country-wide Coronavirus Mortality with Demographics, Testing, Lockdowns, and Public Wearing of Masks
Researchers in Canada, Poland, and the “United” States investigated whether per-capita mortality was reduced in countries favoring mask use (when compared with countries where masks were not advocated). After examining COVID-19 mortality in 200 countries and controlling for a number of variables, they found an independent association between lower per-capita mortality and countries where masks were an accepted cultural norm or favored by government policies on a national level.
A weapon of the scientifically illiterate
Science is a tricky business, and it’s easy to bamboozle people using respected published data but with no regard for the totality of evidence. (Just ask pop culture doctors who will recommend an ingredient for your health based on a study in mice or a flimsy clinical trial.) Committed anti-maskers have a few tactics they use to push their agenda across the web, especially on social media. Among the minority of them who even bother to cite references, a favorite tactic is cherry-picking. This is not only disingenuous; in the context of a public health crisis, it might be considered murderous.
A couple of aforementioned researchers who have prolifically explored mask use are CR MacIntyre & AA Chughtai. In an early paper co-authored by these two and cited widely by anti-maskers, they state that “the results caution against the use of cloth masks”. Yet there are many conditions to this statement, if you know how to read a study. More importantly, subsequent studies and reviews by the same authors paint a different picture. A meaningful statement from the authors in response to a 2020 paper they published is this: “The sum of the evidence cited in our review shows that face masks are protective in the community and consistent with the findings of the individual studies”.
Masks work and always have
In summary, we’ve provided a small sample of myriad available data supporting mask use. The overwhelming majority of credible papers published on this topic lead us to the conclusion that wearing masks during this epic global public health crisis helps stop the spread of SARS-CoV-2, a major source of misery. While vaccines will very likely alleviate this misery in 2021, masks will remain an easy and affordable measure to lessen human misery, in part by aiding health care systems and keeping or taking them out of acute distress.
COVID-19 Update: First week of 2021
Results from a cross-sectional study published in early January reminded us that the death count for COVID-19 is much higher than official numbers. “The number of estimated COVID-19 deaths is also remarkably more than the reported deaths in the US through November 15, 2020, supporting the conclusion that approximately 35% of COVID-19 deaths are not reported”, state the researchers. This reenforces published findings from 2020, and of course it contrasts with the politically motivated anti-science narrative of anti-maskers (that deaths from the plague are only a fraction of what is being reported).
If you doubt the ripple effects of overburdened hospitals, you need only look at how bad it has become in California:
The new curfew in Quebec is controversial, but it comes down to this: if you act like a child when it comes to public health, you will eventually be treated as a child. This is not a drill. Please be responsible.
Further reading (highly recommended):