Resistance to public-health measures is certainly not a new concept; even anti-drunk driving laws received significant pushback as infringement of personal liberties. But no public-health measure has resulted in as much controversy as face coverings.
Even within the health-care sector, there is no consensus on when and how to employ masking interventions or even whether such interventions are justified. Indeed, any intervention-related decision-making must be grounded in the core values of public health, requiring consideration of principles such as health outcomes and the potential downstream impacts and consequences to weigh potential harms and burdens alongside social justice and health equity.
For a universal masking requirement in health-care settings to be acceptable, decision-makers must situate it within the context of public-health ethics to determine whether these mandates are justified. A simple way of discerning this is to use the ethical frameworks of public health. While many frameworks exist, there are a few overarching concepts.
- Is the intervention grounded in public-health goals?
Masking in health-care settings reduces transmission of SARS-CoV-2 virus and therefore COVID-19-related morbidity. The primary route of transmission is via airborne particles and respiratory droplets. Presymptomatic and asymptomatic individuals can transmit the virus, meaning COVID-19 spreads silently. Individuals in health-care settings are more likely to be elderly, immunocompromised or have comorbidities and risk factors for severe COVID-19-related illness, even when fully vaccinated. A meta analysis of 40 global studies shows a high incidence and burden of nosocomial COVID-19 infections. Data from Canada highlights that mortality rates with hospital-acquired COVID-19 infections are significantly higher compared to non-hospital-acquired infections. A systematic review and meta analysis demonstrated similar findings, with the risk of mortality 1.3 times greater in patients with nosocomial infections compared to community-acquired infections. In addition, Canada is facing a health-care worker shortage. Reduction of COVID-19 transmission in hospital settings can reduce further strain on human resources.
- Is the intervention effective in achieving the public-health goal?
While a recent Cochrane review on the effectiveness of masks to reduce the spread of respiratory viruses was inconclusive, potentially because randomized controlled trials are limited in their ability to properly assess public-health interventions, dozens of cluster-randomized and case-controlled studies have shown that a well-fitted mask with good filtration offers inward protection for the wearer as well blocking virus exhaled by infectious people. Studies specific to COVID-19 in health-care settings showed comparable results, suggesting that universal masking with a well-fitted mask worn continually leads to a lower rate of COVID-19 infection among health-care workers and patients. This benefit extends to other respiratory viruses as well.
- What are the known or potential burdens?
Research indicates minimal to no significant adverse effects of mask-wearing. Studies show no oxygen desaturation or respiratory distress occurs, even in low to moderate levels of exercise or in those with lung-function impairment. Face masks worn for longer durations, however, can result in minor skin reactions such as acne, itching and dry skin.
Research indicates minimal to no significant adverse effects of mask-wearing.
Studies evaluating attitudes on mask-wearing have indicated that some believe mandatory masking policies infringe upon personal liberty and disregard rights. However, Section 7 of the Canadian Charter of Rights and Freedoms states that “everyone has the right to liberty” unless “in accordance with the principles of fundamental justice.” Further, mask mandates can be warranted particularly in “cases arising out of exceptional conditions, such as natural disasters, the outbreak of war, epidemics and the like” provided the measure has a rational and reasonable connection and is not “arbitrary, overly broad or grossly disproportionate.”
- Can burdens be minimized? Are there alternative approaches?
Currently, we do not have adequate alternative approaches that are effective in reducing transmission of COVID-19. Vaccine effectiveness against transmission and prevention of symptomatic illness has decreased significantly, particularly with the onset of variants. Regular testing and screening can reduce the risk of transmission but not eliminate it given the limitations of rapid tests and asymptomatic spread. A 2007 Nuffield Council of Bioethics report states that if more than one intervention exists, the one that is least intrusive must be selected. It seems obvious that masking is less intrusive than requiring frequent invasive testing and vaccination.
- Are the intervention’s benefits and burdens balanced?
The COVID-19 pandemic has highlighted disparities and inequities, with the risk and burden of illness concentrated among the disadvantaged, medically vulnerable, marginalized and racialized. The right to health is a fundamental human right; accessing health care is borne out of necessity and unavoidable. Universal masking ensures the vulnerable are protected and reduces the stigmatization of mask-wearers if the policy is implemented for everyone within a health-care institution. A universal mask policy that does not discriminate and balances burdens fairly; although benefits are maximized for the vulnerable, they are nevertheless present ubiquitously.
- Are there any concerns with social justice and equity?
Specific to health-care workers, the Thompson framework on pandemic influenza preparedness clearly outlines obligations toward patients to provide care and protection from serious harm, unambiguously justifying, at a minimum, mask-wearing for health-care staff while at work. As leaders in public health have indicated, “justice requires public-health officials to devise programs with particular attention to the disadvantaged” and public-health policies should not exacerbate health inequities.
In conclusion, using public-health principles, a universal masking policy for workers in health-care settings that protects the health and well-being of those seeking medical care is well-justified.
What is still to be determined, however, is when can such interventions be safely downgraded and/or made less restrictive. We may, in fact, find that mask policies in health-care settings are justified in permanency, and especially during high circulation of respiratory viruses.
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The article titled “What Went Wrong with a Highly Publicized COVID Mask Analysis?” by Naomi Oreskes published in Scientific American in November 2023 addresses the issue of a Cochrane Library report that was misconstrued in the media as claiming that masks were ineffective in preventing the spread of respiratory illnesses, including COVID-19. The article critically appraises the contents of the Cochrane report and argues that the report’s conclusions were based on a too-narrow view of evidence and that it ignored compelling epidemiological data demonstrating the effectiveness of mask mandates:
The Cochrane Library, a reputable source of health information, published a report on the efficacy of masking and physical interventions in slowing the spread of respiratory illnesses, such as COVID-19. The report suggested that wearing surgical masks “probably makes little or no difference,” and the value of N95 masks was deemed “very uncertain.” However, the media widely interpreted these findings as an assertion that masks did not work.
Dr. Oreskes argues that the Cochrane report suffered from several key issues. Firstly, the lead author of the report, Tom Jefferson, contributed to the misunderstanding by promoting the misleading interpretation that masks, including N95s, made no difference. Secondly, there was a failure to distinguish between a lack of conclusive evidence and evidence of ineffectiveness. The report did not state that masks did not work but rather that there was insufficient high-quality evidence to conclusively prove their effectiveness.
The third issue highlighted in the article relates to Cochrane’s approach to defining evidence. Cochrane Reviews primarily rely on randomized controlled trials (RCTs) as the “gold standard” of evidence. However, some questions cannot be effectively answered with RCTs, such as those related to nutrition and flossing. Similarly, the effectiveness of masks in preventing respiratory illness is difficult to study through RCTs. Despite this, there is robust epidemiological evidence showing the effectiveness of mask mandates, as demonstrated by the experience of Kansas and other states.
The article criticizes Cochrane’s methodological approach, suggesting that it adheres too rigidly to a particular definition of rigor and methodology. This approach, known as “methodological fetishism,” can result in the dismissal of valuable studies that don’t conform to the preferred methodology.
The article rightly argues that scientific evidence does not always fit neatly into the confines of randomized controlled trials (RCTs). The effectiveness of measures like mask mandates can be discerned through multiple types of evidence, including epidemiological data. Cochrane’s narrow approach to assessing evidence and its exclusive reliance on RCTs may have led to the misunderstanding of the report’s findings. The article calls for a reconsideration of Cochrane’s standard procedures and a broader view of evidence to better inform public health decisions.
Reference and note: This article was originally published with the title “Masked Confusion” in Scientific American 329, 4, 90-91 (November 2023) doi:10.1038/scientificamerican1123-90 ABOUT THE AUTHOR(S) Naomi Oreskes is a professor of the history of science at Harvard University. She is author of Why Trust Science? (Princeton University Press, 2019) and co-author of The Big Myth (Bloomsbury, 2023).” What Went Wrong with a Highly Publicized COVID Mask Analysis? – Scientific American- https://www.scientificamerican.com/article/what-went-wrong-with-a-highly-publicized-covid-mask-analysis/
There is one major aspect that goes unmentioned here – some patients have disabilities that make mask-wearing anything from slightly challenging all the way to entirely impossible for any length of time.
Healthcare is a human right, even – and especially – for people with disabilities. We don’t deserve to be treated like criminals and/or permanently banned from seeking healthcare.
Thank you for your efforts.
The glaring elephant in the room, (besides dismissing contradictory RCTs as moot and rather, embracing low quality observational studies as gold ) is the actual risk of asymptomatic viral transmission.
New studies call to logic that Mask mandates are warranted based on the assumption that a large portion of healthy people may unknowingly be infected with Covid and could transmit the virus to others
The paper, published in the August issue of the journal The Lancet Microbe, found that infected people presymptomatically very rarely had the ability to infect others.
A second rigorous study this year from Stanford showed the limited ability of most people without symptoms to infect others.
What this means is that compelling people without Covid symptoms to wear masks in any number of environments—including hospitals likely yields far, far less societal benefit than we were told since asymptomatic people are far, far less common than we were led to believe.
The Stanford researchers developed a special test that found 96 percent of people who were PCR-positive but without symptoms were not infectious.
Most people who don’t have symptoms, of course, are not infected. So the likelihood of someone who is not noticeably sick actually being infected and infectious was exceedingly rare.
In June 2020, Dr. Maria Van Kerkhove, head of the World Health Organization’s emerging diseases and zoonosis unit, said that transmission from asymptomatic people was “very rare.”
This sentiment was ( gasp!) echoed by Anthony Fauci as well. … although he backtracked as usual
Authors of an editorial reviewing the evidence of asymptomatic transmission, published in BMJ in December 2020, said “Searching for people who are asymptomatic yet infectious is like searching for needles that appear and reappear transiently in haystacks.”
Citing our constitutional rights to refuse a mask has become a laughing stock of late in Canada – since rights have all but been removed. But ,Please do not even let me begin on the harms of masks. Their harms are common sense : erasure of vital empathy, obstruction of speech comprehension for hearing impaired and ESL populations dependent upon lip reading and facial cues, rebreathing in carbon dioxide, mishandling of a contaminated mask increasing spread of disease, and how about the toll on already burned out health care workers forced to mask day in and day out ?
But alas, none of the above matter in an age were public health thinks they HAVE a to do something ! Anything !! despite its futility.
I guess Canadians should be grateful sadly, that a mask is now public healths “weapon” of choice considering the abuses of lockdowns, vaccine mandates, and social distancing we have endured
Sorry to say but All faith is now lost in these health authorities
This threat is far more dangerous than Covid
Totally agree with you. Bravo for your comments!
The U.S. Centers for Disease Control and Prevention (CDC) has recently initiated work to update foundational infection control guidance for health care settings. The CDC’s advisory committee, the Healthcare Infection Control Practices Advisory Committee (HICPAC), has formed a Work Group to formulate draft updates. The Work Group’s proceedings have been closed to the public—until now.
Canada along with other nations agreed to fund and support the CDC and follow its lead. Early on in the COVID pandemic, when Dr. Theresa Tam was questioned about the use of non-medical masks she responded by saying that public health is a team event. A third of the funding of the CDC comes from industry and their interests unduly influence CDC decisions. Will PHAC continue to follow CDC in regards to protections for healthcare workers and patients? Canada has followed the CDC’s lead on the hidden, ignored Lyme and tick-borne disease epidemic after the insurance industry red-flagged Lyme as being too expensive to treat. PHAC and infectious disease doctors have prioritized the preservation of the antibiotic supply over returning Canadians to health.
CDC Work Group is Focused on Weakening Protections for Health Care Workers and Patients to Create More Flexibility for Employers to Prioritize Profits, National Nurses United: https://www.nationalnursesunited.org/cdc-hicpac-work-group