The Question of Masks

Sometime in late April, the CDC first recommended the general public wear masks to help prevent the spread of coronavirus.  Following this, municipalities and states passed ordinances requiring the wearing of masks.  It should be noted initial recommendations came with the recognition there were no studies to validate the proposal.  In years past, masks outside the medical setting had only been suggested for those who were sick.  The sick exhibit symptoms.  They cough and sneeze and expel a large viral (or potentially bacterial) load into the air.  It makes sense to try and block that expulsion.  However, those who are not sick do none of those things.  Hence the medical community has long rejected the idea of masks for the general public.  In April, it was acknowledged this new step was not done with conclusive data.  However, a large percentage of those who had tested positive for coronavirus were not exhibiting symptoms.  All human beings express some droplets as we breathe and talk.  Therefore, the CDC decided masks may help prevent the spread of this new strain of respiratory disease.

Requiring masks made little sense to me.  The CDC defined a close contact, or at risk event, as remaining within six feet of a COVID positive individual for 15 minutes.  If simply going out in public placed one at risk for that, they shopped a whole lot differently than I did.  I can’t remember staying within six feet of anyone in the grocery store for more than 30 seconds in my entire life.  In addition, if someone was considered a close contact, the presence of a mask made absolutely no difference to the CDC regarding the necessary quarantine.  I will acknowledge they admitted masks were not foolproof, but the idea you still had to quarantine despite having to wear a mask failed to inspire confidence.

Within a few weeks of the CDC issuing their guidelines, the narrative changed.  Although there were still no conclusive studies supporting their claims, public health officials and physicians asked to support the mandates started using phrases like “we know masks work.”  By the summer, those in favor of masks were emboldened by a study from Wei Lyu and George Wehby
1.   It examined the COVID-19 growth rate before and after mask mandates in 15 states and the District of Columbia between the end of March and late May.  They concluded these mandates led to a marked slowdown in the daily growth rate.  Their results were cited extensively in articles supporting masks thereafter.  However, if daily growth rate of coronavirus before and after masks is the measure used to determine the effectiveness of masks, it would be difficult for anyone to argue for their continued use.

Mask mandates are currently far more widespread in the US than 15 states and the District of Columbia.  Yet, the headline of every major news organization on Sunday, October 25 related to record numbers of Americans being infected with COVID-19.  The numbers have been quoted and rising every day since.  According to Our World in Data, cases in California went up by over 300% after their mask order in June.  Hawaii, which mandated masks both indoors and outdoors, saw their cases go up by almost 1000%.  That trend is not limited to the United States.  France has 10 times the daily rate since implementing mask requirements, and both Spain and the UK have 15 times the level of cases.  Mask ordinances have also failed to stem a rapid rise in number of cases in Ireland, Belgium, Germany, and Austria.  Meanwhile, the Scandinavian countries of Sweden, Norway, and Denmark have no mask mandates and are not currently experiencing the explosive case rates illustrated above.

If masks are ineffective, the fact it is unnatural to have our mouths and noses covered should be enough for these mandates to be lifted.  The reality is that almost everyone finds them uncomfortable.  It has been stunning to me in 2020 to hear proponents of masks deny this discomfort.  I have heard them discuss how freely they breathe with their face covered.  However, any study on masks conducted before 2020 will cite high rates of discomfort with the use of masks.  A study from 2019 in BMC Infectious Diseases regarding contamination by respiratory viruses on the outer surface of medical masks found 84% reported problems
2.  Complaints included facial pressure, breathing difficulty, pain, trouble communicating, and headache.  I was not researching this article to find evidence of mask discomfort, however.  I was researching this article because there are several ways in which masks could be making things worse.

In all of my public pieces and appearances regarding coronavirus, I have attempted to allow people the opportunity to acknowledge what they are able to see with their own eyes.  I have certainly never minimized the loss of those who have succumbed to this very real disease.  The potential risk to the elderly and those with comorbidities has been acknowledged.  Unfortunately, many of our interventions have not protected that population but have harmed others.   In the case of masks, we have seen, conservatively, hundreds of thousands (likely millions) of cases of “maskne.”  This is acne either exacerbated by or completely secondary to wearing a mask.  Acne is caused by (in addition to blocked pores) an overgrowth of Cutibacterium acnes.  In my clinic, I have also seen patients who have suffered from nasal sores, pleurisy, and stridor.  Are these things not evidence that perhaps it is not a good idea to concentrate bacteria and viruses around our mouth and nose for hours at a time?  There is no disputing the role of the immune system when it comes to coronavirus.  Inflammation certainly appears to be a factor as well.  The presence of acne and nasal sores in many would argue for a taxing of the immune system and increased inflammation.

When widespread mask use was first recommended, opponents argued oxygen saturation would be affected by prolonged use and some exhaled CO2 would be trapped behind the masks.  A 2008 study entitled “Preliminary report on surgical mask induced deoxygenation during major surgery”
3 describes those concerns.  After the first hour, pulse rates of surgeons increased and saturation of arterial pulsations (SpO2) decreased.  We hear many assertions in 2020 along the lines of, “the data speaks for itself” without any actual presentation of that data.  This article did not do that.  It considered other possible explanations for these findings.  Operational stress was recognized as a possible contributor.  Physiologic changes of nurses in my office can not be attributed to surgical stress.  The physical workload of those nurses is considered “light” by occupational standards.  Although they walk frequently, they rarely carry objects weighing more than a few ounces.  When mask mandates in Alabama were first announced, our office purchased surgical masks.  According to their Apple watches, every nurse experienced a significant increase in heart rate.  Doing the exact same job under the exact same conditions otherwise, heart rates ranged from 12 to 22 beats per minute higher with masks.  Although their stress is considerably higher, surgeons stand in one place in an air conditioned, usually cool, environment.  Even minimal physical exercise seems to exacerbate the effects of masks.  If oxygen saturation is not affected and CO2 does not accumulate behind masks, I am at a loss for other explanations of this tachycardia.  A transition to cloth masks has alleviated some of those effects. I have discussed it with other health professionals, some of whom wear masks throughout the day, and admit some report they notice no difference wearing a mask.  However, I think many of you could replicate the experiment described in my office using your own Apple watch and see similar results.

Listening to certain public health officials and politicians, they emphasize the word “respiratory” when it comes to describing COVID-19 as a respiratory virus.  However, the word respiratory refers in large degree to the part of the body most affected.  Although we undoubtedly shed the virus in respiratory secretions, we don’t necessarily contract respiratory viruses simply by breathing shared air.  It is, of course, a possible source of transmission, and there could be a virus in the future that has me donning all kinds of PPE, but it has not been my experience so far.  For fifteen years I entered dozens of patient rooms daily treating individuals with respiratory viruses such as influenza, parainfluenza, rhinoviruses, coronaviruses, RSV, and respiratory adenoviruses.  I never wore a mask and I never got sick.  I put my children in daycare and I got sick.  Why?  Because they were too little to know better than to put contaminated foreign objects in their mouth and they were the only human beings I ate and drink after.  We generally get sick when we put a virus directly into our mouths and noses.  This experience can be confirmed by essentially every doctor in America.  Undoubtedly in 2020 there will be those who would argue otherwise.  But, again, trust what you have seen with your own eyes.  When you went to a doctor’s office, urgent care center, or emergency room in 2017, 2018, 2019, January, or February, were the doctors and nurses who attended to you wearing a mask?  If we are that vulnerable to simply breathing respiratory viruses, wouldn’t they have worn them every flu season?

So if we are more likely to contract a disease from putting it in our mouths and noses, masks could well contribute to rising rates of infection.  From the acne observation, it seems likely potential pathogens accumulate on the surface of masks.  From the 2019 BMC Infectious Diseases study referenced above, we know they can accumulate on the outside of those masks.  Among those pathogens is COVID-19.  People adjust, touch, lower, and replace their masks frequently.  Once an individual’s hands are contaminated with the concentrated pathogens, they deposit them on surfaces.  If that surface is Chips Ahoy at the grocery store, and they decide not to purchase the item, the next customer is vulnerable.  They open the package, reach inside with a contaminated hand, and insert the virus along with the cookie.  Interestingly, even Good Morning America cautioned against just such contamination prior to the CDC reversing its stance.
4

The psychological damage of masks is difficult to argue.  Joy, anger, fear, surprise, sadness, contempt, disgust.  These basic building blocks of communication are written all over our faces.  With physical distancing, increased anxiety, and disrupted routines due to coronavirus, we are primed to seek emotional connection simply by seeing each other’s facial expressions.  Children are especially affected.  Many young children burst into tears when someone wearing a mask approaches.  Before COVID, some elementary schools prohibited masks at school Halloween parades for exactly that reason.  One reason is the development of facial recognition is relatively weak in young children.  This is especially true of those on the autism spectrum
5.  The incidence of anxiety disorders has risen considerably among children and there are now reports of problems with speech development.

I do not purport to have all the answers when it comes to masks.  I do feel the evidence against them outweighs the evidence for their use.  And I find it concerning that we are bombarded with ads over a practice that was universally rejected by the medical community prior to 2020.  Even Dr. Fauci, when asked about masks in March, dismissed the idea
6.  Later, it would be suggested he was simply worried about having enough masks for health care providers.  However, that contrasts sharply with his emphasis and demeanor in the original video.  I also know that a large proportion of the funding for advertisements encouraging people to wear masks comes directly from governmental health departments.  It has made them major advertisers which discourages radio or TV stations from investigating or reporting their actual effectiveness.  It is this absence of reflection and discussion about our approach to the coronavirus that most concerns me.

Revision:  Although my original paper ended with the above paragraph, I have found an article that does present definitive answers when it comes to masks.  “An Evidence Based Scientific Analysis of Why Masks are Ineffective, Unnecessary, and Harmful”
7 by Dr. Jim Meehan.  Dr. Meehan’s work details decades of the highest-level scientific evidence which overwhelmingly conclude medical masks are ineffective for preventing the transmission of respiratory viruses.  He also does an excellent job of detailing the inconsistencies of public health authorities and the harm masks are inflicting upon our children. 

And a link to the NBC News Sunday Today piece
8 presented to the council.