Reflecting on Mask Mandates in Healthcare
Reasonable thoughts after reading the title of this piece include:
“What the hell is he thinking writing about mask mandates in healthcare centers? His twitter followers seem to be to the left of him and the Sensible Medicine commenters seem to be to his right. This is sure to end badly.”
“He said he would stop tweeting about COVID in March!”
“Just sharing Vinay Prasad’s Sensible Medicine post on mask mandates had people yelling at him.”
“Why in the world did Dr. Prasad include a picture of a turtle being strangled by a mask in his post?”
Bear with me for a 10-minute read.
I honestly don’t know where I stand on this issue. On the one hand, I feel like an idiot because so many people seem so sure about where they stand. On the other hand, people with completely opposing views cannot all be correct.
I am going to present three proposals, all are ones that a good number of people support – there is no straw man here, trust me, I’ve read all the tweets and all the comments. Two of the policies sit at the ends of a spectrum, one is near the center. I’m going to do my best to lay out the arguments for and against each. I won’t restate pro and con arguments that clearly carry from proposal to another.
Maybe this will help me to clarify my thinking. Maybe it will clarify or moderate yours. Maybe it will just get you mad at me.
Before I start, there are three things that I’m sure are true but remain controversial. Take these as my starting assumptions – please let’s not debate these.
A. Masking in healthcare facilities reduces respiratory infections. Healthcare centers are not villages in Bangladesh. We have high quality masks. We are in rooms with a small number of people and can assure that everybody is properly masked. I went 10 months, unvaccinated, seeing patients every day, many who had COVID, without getting COVID (I was tested weekly) because my patients and I wore masks – first cloth, then surgical. At some point I began to wear an N-95 when the patient had, or was very likely to have, COVID (though at the start N-95s were only recommended during aerosol generating procedures). Oh, and I’ve seen patients with TB about half a dozen times/year for 30 years wearing N-95s without converting my ppd.
B. COVID carries less risk now than it did in 2020. Most of us have pretty good immunity. An enormously greater proportion of people who get COVID now, compared to 2020, have either no symptoms or an old fashioned cold.
C. People do still get sick and die from COVID, either from the infection itself or from COVID exacerbating pre-existing conditions. (Actually, a lot of people still get sick: the 150,000 predicted deaths in 2022 will make it the 3rd leading cause of death).
So here we go, the three proposals. As we look toward the end of our 3rd year of living with COVID, how should healthcare facilities handle mask mandates?
Proposal #1: Masks should be mandatory, permanently, in all healthcare settings.
Supporting this Proposal
Over the centuries, our infection control procedures have evolved as we learn more and tolerate less risk. (As many on twitter kindly pointed out to me) we wash our hands before examining patients. After our experience with HIV, we adopted universal precautions. If I were to listen to a patient’s lungs through her gown without washing my hands or place a PPD without wearing gloves, there would be near zero risk to all involved. Despite this, we accept hand-washing and universal precautions as standard. Most of our interactions put patients and doctors at little risk of COVID or other respiratory infection but mandatory masking would decrease that small risk. Fewer patients would be sickened – some seriously. Fewer healthcare workers would be sickened, rarely seriously but often causing staffing disruptions.
Masking is easy, well tolerated by most, and does little to disrupt healthcare.
It will be years, maybe decades, before we have facilities equipped in such a way to reduce our risk of respiratory viruses.
Against the Proposal
If we are honest, everybody, doctors and patients, are more comfortable without masks. We all take our masks off when we get home. We are only happy to wear them when we feel their protection outweighs the (for most, minimal) discomfort. We are human beings; we communicate with our faces as well as our voices. Some patients struggle to understand a doctor wearing a mask. During high stakes interactions, I personally have felt the my effectiveness was limited by masking.
The vast majority of time, masking will not prevent transmission of respiratory viruses, because there is not a respiratory virus to transmit -- neither patient nor doctor is infected or susceptible.
Proposal #2: Masks should be mandatory in high-risk areas (ERs, clinics, wards with a high percentage of immunosuppressed patients…). Masks should be mandatory at times when respiratory virus (COVID, Flu, RSV…) risk is high. At low-risk times and in low risk areas, mask use should optional with policies that ensure that either doctor or patient can request masking.
Supporting the Proposal
What were we ever thinking intubating people without wearing masks or seeing patients with significant immunosuppression during cold and flu season unmasked? There are times and places where everybody should be masked. There are other times and places where we should be willing to accept some risk of respiratory viruses, life is not risk free. Yet, we should moderate risk when the risk is high. We should define a level of community transmission of a list of important respiratory pathogens that call for facility-wide masking. Local public health officials should be tasked with making this call for local institutions.
Some patients and some doctors will, from now on, always want to be masked. This is fine. This can be included in a patient chart – I know of no doctor who would decline to wear a mask if asked by a patient. If a patient is troubled by always having to wear a mask while seeing a masked doctor, he or she can find another doctor.
A version of this proposal is probably what the the CDC is heading for as announced last week.
Against the Proposal
Primarily those listed in #1. Because there will be less mandatory masking, there will be less difficulty with communication. The barriers to unmasking when patient and doctor prefer, and consent, will be low.
Proposal #3: Masks should be optional in health care settings.
Supporting the Proposal
We truly have no idea of the benefit of mandated masking. Especially in late 2022, we have all become sensitive to infection risk. ER doctors may never choose to unmask. I will never again see patients when I have a cold unmasked and will never again see a patient with an influenza-like illness without wearing a mask. (Heck, I’ll never again sit on a train next to someone who is coughing without pulling an N-95 out of my bag). This rational behavioral change lowers the relative benefit of a mandatory mask policy compared to the benefit that would have been associated with it in 2019. This policy does not ban masking.
In order to adopt one of the more compulsory options (proposal #1 and #2), we need to study the intervention. This could be done in cluster RCT during the 4 quarters of 2023. We could see if there is a benefit and, if there is, what the magnitude is. Changing medicine, a place where some of our most important human interactions happen, to a sphere of human interaction where most people are masked most of the time is an enormous step to take without data. Do we want students to be presented with a mask with their white coat and stethoscope (and branded Patagonia fleece) at the White Coat Ceremony?
Against the Proposal
Essentially the pro argument outlined in options #1. If masks become completely optional, there might develop a maskers vs. non-maskers, us vs. them environment in health care facilities – certainly not something we want.
I welcome your thoughts.
What have I missed?
Can you add to an argument for or against any of these proposals?
Anecdotal evidence is not evidence. Your arguments for masks are all based on this. Masks do not, and cannot, by the laws of physics reduce respiratory infections.
But is a healthy, well-paid doctor who spends a lot of time in such settings likely to be more resistant to such infections than a sickly, old man? Yes.
You cannot start with, "I have always worn a mask and did not get Covid" and make it valuable. In contrast, I spent the pandemic in a building full of people with Covid, without wearing a mask and did not get Covid, either.
Was your mask the reason for my good health? Or is it more likely that we both have some sort of natural immunity against severe expressions of the common cold? My money's on the latter, because there's no chance of the former being true.
If people want to clutch at their blankie because they think it will save them from the monster under the bed and this clutching harms no-one? Let them do so. But mandates of worthless measures to placate these cowards? That's insane.
And for the record, I read a dual honors program in Chemistry and Physics at Keele University before going on to work for big pharma. I am well qualified to make accurate judgements in this field, certainly as much as any mask-wearing medic.
And finally, there is emerging evidence (and a growing base of such evidence) that not only do maks not prevent the spread of Covid, they may actually promote it. I assume this is because, though worthless in their own right, masks give people additional levels of "false confidence" to hang out with the infected. Your little chart takes no account of this at all.
You are seriously underestimating the discomfort and annoyance of masks for many people, especially now that masks are gone from the rest of life.
I am not the only person I know who has been avoiding routine medical care because I’m waiting until the masks are gone, both for myself and for my children. Can you imagine trying to put a mask on a baby for the first time simply for a 2yo well visit, to comply with the pediatrician’s policy? There’s no way.