Americans hate masks, but there’s no safely ending the pandemic without them
The face coverings are a cheap, effective and powerful tool that will help us get through future surges.
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Don’t throw your masks away just yet.
With covid cases creeping up in several northeast cities, the face coverings are making at least a limited comeback. Philadelphia will reimpose its indoor mask mandate next week — the first major city to do so. Many universities, including Johns Hopkins, Georgetown and Columbia, are again requiring masks in classrooms. And the Biden administration has decided to extend its mask mandate for air travel by two weeks to monitor the uptick in covid cases; the policy was set to expire on April 18.
It’s not clear yet whether this is a minor bump as the country once again tries to resume a more normal daily routine, or whether it heralds another wave of infection like the one battering much of Europe.
The whipsawing of mask mandates illustrates the tension inherent in returning to normal while the virus still rages. Infections, hospitalizations and deaths will continue to surge and ebb as humanity comes to immunological terms with the coronavirus. The onus is shifting to individuals to determine what level of risk they face — and what level they are ready to accept — and act accordingly.
That’s made all the harder by the federal public health officials’ messaging failures on masks, beginning in the earliest days of the pandemic. As the crisis dragged on, masks came to symbolize the political polarization that has hampered efforts to contain the virus. Evidence shows masks have prevented many deaths, but their controversial status has limited their ultimate impact.
During the relative lull of the past two months, indoor mask rules have largely vanished. The Centers for Disease Control and Prevention relaxed its guidelines in late February; in an instant, the number of counties where masks were warranted under the agency’s approach dropped from more than 90 percent to 37 percent. Soon after, President Joe Biden delivered his State of the Union address to a chamber of barefaced lawmakers, a signal that the country had reached a new phase of the pandemic.
Masks remain a cheap, accessible and effective tool for limiting both individual infections and tamping down community spread. But widespread masking, necessary for shielding the most vulnerable, is becoming less and less workable in a polarized and pandemic-fatigued public. An unwillingness to don masks when cases surge could make getting to the end of the pandemic harder than it needs to be.
Federal officials muddy the waters
Much of the confusion about when, where and how to wear masks stems from confusing guidance from U.S. public health authorities, beginning in the earliest days of the pandemic.
The CDC at first advised against masks for the public, while emphasizing the importance of hand-washing and social-distancing — in part because scientists weren’t on the same page about the best mask policies early on. The CDC and the World Health Organization believed that SARS-CoV-2 was transmitted by droplets, which fall to the floor or other surfaces shortly after being expelled from a person’s nose or mouth. A small group of experts quickly started pushing the agencies to consider the possibility that the virus could be transmitted by aerosols, much smaller particles capable of floating in the air for hours — increasing the importance of widespread mask-wearing to prevent infection. These researchers highlighted outbreaks among people in poorly ventilated indoor spaces that suggested the virus spread much farther than just six feet.
“A lot of people expect that it is easy to do the kinds of research that would be helpful to answer the question. And what we saw was, there’s a number of different ways you can look at how this is transmitted, but it still might not give you really good information about what happens in the real world,” said Glen Nowak, who directs the Center for Health Risk and Communication at the University of Georgia and who served as director of media relations at the CDC during the 2009 influenza pandemic.
Supply chain issues also played a role in forming the U.S. government’s initial advice to a worried public in early 2020. “Seriously people- STOP BUYING MASKS!” then-Surgeon General Jerome Adams tweeted in March 2020 (a post he later deleted). “They are are NOT effective in preventing general public from catching #Coronavirus, but if healthcare providers can’t get them to care for sick patients, it puts them and our communities at risk!”
“You don’t want to tell people to do something that they then can’t do, because it creates anger, frustration,” said Nowak.
Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Disease (NIAID) later told InStyle magazine that the early recommendation against masking was based largely on the fact that masks needed to be saved for healthcare professionals at the time. He also cited uncertainty regarding asymptomatic spread and the efficacy of the cloth masks that individuals who couldn’t get N95s would have to wear as contributing to the decision to recommend against mask use.
By early April 2020, the CDC began recommending that Americans wear masks in public spaces, but it said that cloth masks were sufficient for most people. That fall, the agency began calling for students and teachers to mask up at school. And when President Joe Biden took office in January 2021, one of his first acts was to sign executive orders requiring that masks be worn during travel and in federal buildings and on federal lands.
In May 2021, the CDC updated its guidance to acknowledge that the virus is airborne — and advised that masks should be worn indoors even if people were standing more than six feet apart. A week later, the agency said that fully vaccinated people did not need to mask up in most situations. By then, masks had become a hot-button political issue in large swathes of the country, and many people were simply confused about when and where to mask up.
Conflicting messaging about mask-wearing was one notable failure of public health messaging during the pandemic, according to a December 2021 paper summarizing discussions at a series of meetings held by the National Academies of Sciences, Engineering, and Medicine. “During the COVID-19 pandemic, complex information about the rapidly expanding, escalating, and evolving public health crisis was disseminated with insufficient attention to explaining why something was happening or needed to be done,” the paper’s authors wrote.
The study also highlighted a disconnect between federal policies and messaging at the local level, due in part to a lack of funding to help disseminate key public health messages around masks and other precautions.
“Underfunding, for example, can lead to problems like delayed translation of materials. We heard in some places, it would take a few days to translate what was said in a press conference, so some community members were consistently getting information that was outdated,” said Katherine Schaff, health equity coordinator at Berkeley Media Studies Group.
As more and more people have some level of immunity from vaccination, prior infection or a combination thereof, the metrics guiding the CDC’s masking advice have changed. The agency now advises people to wear masks indoors only if their local hospitals are strained, rather than calling for mask-wearing in areas of high covid transmission. That represents a shift away from basing masking decisions on a person’s individual risk of contracting the disease.
“It makes sense that you evolve toward looking at healthcare systems and their capacity, their ability to treat people, whether they have covid or not, because at the end of the day, they have to be ready to treat people or diagnose people and treat people for whatever illness they have,” said Nowak.
But some experts are dissatisfied with the approach because it risks leaving people who are immunocompromised or at high risk of severe disease with little clarity.
Nowak said that in the future, he hopes public health communicators apply strategies from the related risk communications field: “You acknowledge uncertainty. You recognize that there are different approaches and options, each with its own strengths and weaknesses, and you share that with people. You foreshadow the fact that your recommendations are tentative and will change.”
A powerful tool
The coronavirus’ modus operandi is relatively simple: Hitch a ride on tiny droplets and airborne particles exhaled by infected people, and wait until those particles get inhaled by a potential host.
Masks thwart this scheme by capturing virus-laden particles as they’re exhaled and before they’re breathed in. It’s a numbers game: The more particles captured, the greater the protection to both the wearer and those around them.
“Masks are basically filters strapped to your face,” said Aaron Collins, a mechanical engineer with a background in aerosol science who posts on YouTube as the “Mask Nerd.” How well those filters work depends on how well the material traps particles and how snugly the mask fits. Even the highest-quality mask — such as an N95 — can’t stop the virus from entering gaps around the cheeks or nose.
Basic cloth masks block most large droplets larger than 20 or 30 microns (less than half the thickness of a human hair) that might contain viruses. But cloth masks are worse at capturing smaller particles called aerosols that can remain airborne for hours and are bigger drivers of transmission, especially indoors where they can accumulate.
Thin neck gaiters, for instance, capture only about 10 to 15 percent of aerosols, Collins said. Upping the density of the cloth, doubling up and ensuring a good fit can bump filtration efficiency up to 50 to 60 percent. Surgical masks capture 70 to 80 percent of particles, depending on the fit. Gold-standard N95 masks use electrostatically charged polypropylene filters and snug-fitting design to block 95 percent of aerosols 3 microns or larger.
This lab-based data largely tracks how well various masks protect wearers from coronavirus infection in the real world. A CDC study of nearly 2,000 Californians found that consistent indoor masking significantly lowered the odds of testing positive. Cloth masks reduced risk by 56 percent, surgical masks by 66 percent and respirators (KN95s or N95s) by 83 percent. “Cloth masks are better than nothing,” Collins said, “but we have better technology and should absolutely use it.” While N95s were scarce early on, the CDC now has a website directing people to free ones.
Coronavirus transmission would drop close to zero if everyone wore a fitted N95 mask at all times indoors. That won’t happen, but an array of studies have shown widespread mask-wearing of all types can significantly curb covid, said Catherine Clase, an epidemiologist and member of the Centre of Excellence in Protective Equipment and Materials at McMaster University. “The idea that masks don’t make a difference to transmission is a myth at this point.”
In Bangladesh, a real-world masking experiment found that villages where cloth or surgical masks were distributed and promoted tripled mask use to 42 percent, compared with 13 percent in villages that didn’t get masks. That cut symptomatic seroprevalence, or people with covid-like illness who tested positive for covid antibodies, by nearly 10 percent, and by 35 percent among older adults wearing surgical masks.
Observational studies find similar results. Mask-wearing in the close quarters of the USS Theodore Roosevelt reduced risk of infection by 70 percent among Navy service members. Schools without masking requirements were 3.5 times more likely than schools with masking requirements to experience a covid-19 outbreak. Another study found that universal masking in schools cut in-school transmission by nearly 70 percent. Counties with mask mandates had 5 to 27 percent fewer cases than counties without.
It’s difficult to measure the precise impact of community masking because of many confounding factors, but the totality of evidence suggests masks protect both the wearer and the community, Clase said, especially when more people wear masks, and more of those masks are higher-quality.
Mask quality has become increasingly important with the arrival of new, more transmissible variants. Delta and omicron aren’t riskier because they’re better at weaving through mask fibers; rather, infected people may kick out more viral particles, and those particles are more likely to kickstart an infection if breathed in. “Masking gives you a proportionate reduction in the particles that come through your mask,” said Clase. “If the particles out there are more infectious, then you’re going to experience a greater risk, and ideally you’ll have a better mask.”
Universal mask-wearing reduces those particles for everyone, keeping the overall risk lower. But despite these more transmissible variants, indoor masking rules have been largely lifted across the U.S., and the CDC’s updated masking guidance is much less conservative. Alyssa Bilinski, an infectious disease modeler at Brown University, and a colleague found that under the new guidelines, masking recommendations kick in only after projected deaths reach 1,000 per day. “By the time we hit these case numbers, we expect to have a very high level of mortality already baked in,” she said.
The rollback of mask mandates places the burden of protection on the most vulnerable, including the elderly, immunocompromised and unvaccinated, Clase said. Wearing a high-quality mask reduces risk for these people, but it cannot eliminate it. When cases are low, that risk may be manageable. But during surges, it becomes increasingly untenable, Clase said. “It is just so wrong that we are not prepared to protect people in our society who are more vulnerable.”
The coronavirus isn’t done evolving, and we very well face future surges or variants that are even more transmissible than omicron (including the latest flavor, BA.2) or evade existing immunity. Other tools, like vaccines, might have to be tweaked in the face of new variants, but masks will remain a cheap, powerful and responsive tool for curbing covid, especially when widely adopted. “The cost of wearing a mask is really quite small compared with the impact it can have across society,” Clase said.
How face coverings became a flash point
For about five weeks, beginning in March 2020, covid-19 mitigation measures — including shutting down travel and restaurants, closing schools, and limiting gatherings — enjoyed widespread bipartisan support, according to the Pew Research Center. But over time, favorability toward these measures split along party lines. Republicans and Democrats diverged significantly over whether they felt ready to return to normal, whether they agreed that ordinary Americans could affect the virus’ spread and whether increased caseloads corresponded with an increase in testing.
Masks became a stand-in for much of this divide, reflecting people’s frustrations with the pandemic and standing in as an expression of partisan identity and philosophical ideals of individual liberty and social commitment.
That divide was helped along by public officials. In the earliest days of the pandemic, when the virus was least understood, health officials sent mixed messages that stuck in public consciousness. Then-President Donald Trump also decried masks publicly and tweeted mocking images of those who wore them, including of Biden, then a presidential candidate.
Consequently, research has consistently found that political identity was the largest indicator of whether or not a person complied with covid-19 mitigation measures, including masks.
In a 2021 study, University of Chicago researchers reported that, during the first year of the outbreak, “the single most important predictor of local mask use last year in the United States was not covid-19 severity … [it] was what percentage of people in an area voted for Donald Trump in 2016.”
Mask adoption reflects political attitudes about individualism and collectivism, the researchers wrote. In this way, it becomes more of a symbol of “political belonging” than other mitigation methods. That rift grew significantly in the pandemic’s second year.
In February 2021, after a winter that saw the then-worst surge of covid-19 cases, most Americans said they wear a mask all or most of the time in public indoor businesses, including 93 percent of Democrats and 83 percent of Republicans. But by August 2021, only about 30 percent of Republicans still said they did compared with 71 percent of Democrats. That 40-point gap persisted even through January 2022, when new coronavirus cases were at an all-time high.
Now, more than two years in, most Americans report wearing a mask indoors at least sometimes and are about evenly split on whether to lift mask mandates, according to a poll the Kaiser Family Foundation released last week. But respondents split starkly along party lines: 85 percent of Democrats agreed that “people should continue to wear masks in some public places,” while 69 percent of Republicans agreed with the statement, “People should stop wearing masks in most public places so things can get back to normal.”
This political divide has echoes in the 1918 flu, Einav Rabinovitch-Fox, a professor of U.S. and women’s and gender history at Case Western Reserve University, wrote in an essay for the Washington Post.
In that case, pro- and anti-mask divisions reflected culture wars over gender and patriotism, according to Rabinovitch-Fox. Resisters of mask-wearing equated them with weakness and femininity, while mask-supporters appealed to notions of civic pride to encourage their adoption.
Unlike today, however, those divides weren’t necessarily partisan, Rabinovitch-Fox added, but were “still imbued with the contemporary politics of the day. Similar to this current moment, masks became a conduit to discuss the limits of government power, as well as if and how much authorities should intervene in individuals’ lives and the economy in the name of public health.”
In parts of East Asia, mask-wearing is a common practice, gaining traction after the outbreak of severe acute respiratory syndrome (SARS) in China in 2002. Over the course of two years, an estimated 774 people died out of 8,098 reported cases, according to the World Health Organization.
In a paper published in the Journal of Epidemiology and Public Health, U.K. public health researchers found that the public response to this epidemic surpassed even public guidance, and that mask-wearing helped build “awareness of the collective and personal responsibility in combating infectious disease.” In this way, the researchers found, the face mask became a symbol of commitment to public health — and has seen far less partisan divide over its adoption.
Despite early messaging failures and confusion around the usefulness of face masks, the evidence now clearly shows they can play a powerful role in curbing covid. The crucial question going forward is one of public perception: whether Americans will be willing to put masks back on when another surge hits.
Thanks to Lillian Barkley for copy editing this article.