Of Masks and Men

As scientists, we all pride ourselves on worshiping at the altar of data. Data is king, after all, and during times of uncertainty, we look for anchors. However, nothing is absolute in science or in medicine. Indeed, the Hippocratic Oath emphasizes the moral obligation to respect patients, consider our role in society, and be aware of our own limitations. The greatness of science is that it is dynamic, and we will never have all the answers. The role of medicine is to keep society safe but to maintain a balance between our commitment to science and our understanding of human behavior.

In "Masks and Face Coverings for the Lay Public" by Czypionka and colleagues (1), the authors bring up some interesting observations about cultural variations affecting mask wearing. Although mask wearing was already normalized in several non-Western countries and, therefore, mask mandates were easily accepted, mixed messaging about the role and efficacy of mask wearing led to a public resistance to similar mandates in the United States. Data at the start of the SARS-CoV-2 pandemic supported mask wearing indoors, where the risk for viral transmission was well documented. The World Health Organization did not recommend mask wearing while exercising outdoors in 2020. Various studies from Asia that looked at large outdoor gatherings did not report outdoor transmission. Public health messaging in the United States, however, ignored these data and continued to tell everyone to wear a mask. Everywhere. All the time.

In what has become commonplace during times of duress, Americans took to tribalism and virtue signaling. Those who wore masks were good, kind, science-following intellectuals. Those who weren’t were….well, the opposite. Mask = good. No mask = evil. Both teams dug in their heels, and the divide was made even worse in the context of a contentious election year. If 1 mask was good, 2 masks were better, right? Meanwhile, half the country saw mask mandates as an infraction on personal liberties, some going so far as to call the virus a hoax.

Similar to “abstinence only” campaigns, public health messaging failed to meet people where they are. Officials spoke in scientific jargon, allowing the media to translate the facts. We battled misinformation along with SARS-CoV-2 daily, but the media apparatus was far too powerful for even the most respected medical institutions. It is said that a lie can travel around the world while the truth is putting on its boots. Before 2020, the most difficult medical myth I heard was the oft reported but false link between proton-pump inhibitors and dementia. Thanks to the pandemic, I now long for those days. I have had to digest the massive amounts of legitimate (and illegitimate) medical literature while keeping up with the never-ending geyser of conspiracy theories and new policy mandates. I have never encountered this level of misinformation in my medical career.

I view this pandemic as both a triumph of science and a failure of policy. In 1950, Volvo developed the seat belt as we know today. Seat belts were shown to save lives and make automobile travel safer, but they only became mandatory in all new vehicles in 1968. Seventy years later, we still cannot convince 100% of the population to use seat belts all the time, but we have convinced the majority, and that’s a public health success. The journey from data to behavioral change is long and arduous. The fact that we contained this pandemic by developing highly effective vaccines within 1 year is frankly awe inspiring to me, but Operation Warp Speed belies the several decades of hard work and innovation that allowed this to happen. Our messaging and policy decisions need to catch up to the nuance of our scientific methods.

I end all my clinic visits now by asking my patient if he or she has received the SARS-CoV-2 vaccine. If so, I congratulate him or her. If not, I offer an opportunity to answer any questions about the vaccine. Some patients answer with a curt, “No.” However, many appreciate the opportunity to share any reservations they may have, and I have enjoyed the opportunity to have this important conversation. In my experience, numbers and facts rarely move the needle on this issue. Patients respond to trust, patience, and mutual respect. Most important, they want to know that I will accept them, no matter their views.

Recently, the Centers for Disease Control and Prevention recommended that fully vaccinated Americans ditch their masks. Ironically, vaccinated people who choose to continue to wear a mask in the face of this new recommendation are being chastised by some in the scientific community. Behavior previously considered as cautious and scientifically vetted is now ridiculed, to which the mask wearers say, “It’s my right to wear a mask if I want.”

The truth is, none of these mask mandates or policy decisions were truly fact based, and we need to be transparent about that. Human behavior is complicated. We will change behavior so long as it aligns with our own personal values, and our values may even change, depending on the perceived threat. Students in South Korea returned to in-person classes in waves, limiting the density of students by 8 June 2020, with a limited effect on increase in new cases (2). Even in a postvaccine world, the reopening of U.S. schools in 2021 still seems uncertain. Children and young adults in this country have lost an entire year of unquantifiable social and educational development based not on facts but on fear.

When outdoors, I continue to not wear a mask. However, in public, indoor spaces, such as  grocery stores, I continue to wear one. I recognize that I don’t have to do this, but I still plan to. Why? To make others feel safe. To keep those who cannot receive the vaccine or who live in an immunocompromised state safe. To model responsible behavior to those who may not share my views on this virus. Because I haven’t gotten so much as a cold for the first time in a 14-month stretch. Mostly because it is more important to ease discomfort than to be right.

I trust science, and I continue to let data drive my medical decision making. However, to beat this virus together, we all have to put down our armor. The masks will follow.

References

1. Czypionka T, Greenhalgh T, Bassler D, et al. Masks and face coverings for the lay public: a narrative update. Ann Intern Med. 2021;174:511-520. [PMID: 33370173] doi:10.7326/M20-6625
2. Yoon Y, Kim KR, Park H, et al. Stepwise school opening and an impact on the epidemiology of COVID-19 in the children. J Korean Med Sci. 2020;35:e414. [PMID: 33258334] doi:10.3346/jkms.2020.35.e414