It’s Time to Face Facts, America: Masks Work

“Originally, I agreed that only sick people should wear masks,” said Linsey Marr, an environmental engineer who studies disease transmission. “After observing this pandemic, I now think that if we had an infinite supply of masks, everyone should be wearing them when they go out in public.” Benjamin Cowling, an infectious disease epidemiologist, agreed: “If there were a plentiful supply of cheap face masks, I believe there would be a recommendation for mass masking. We need to consider the use of masks going forward as supplies permit and develop evidence-based guidelines for homemade versions.”

Given the shortage of respirators and surgical masks in many parts of the world, textile companies, scientists, and citizen tailors are racing to invent and craft alternatives. Hanes, Fruit of the Loom, and Parkdale Mills are manufacturing masks from three-ply underwear fabric. Fashion designer Christian Siriano and his 10 seamstresses hope to produce several thousand masks each week. The fabric company Joann has released video tutorials for sewing masks at home. Scientists in Hong Kong are teaching people how to make a mask from tissue paper, paper towels, tape, and a twist tie, coupled with a transparent file folder binder-clipped to glasses to serve as a face guard. Joe Fan, assistant hospital chief executive at the University of Hong Kong, says the paper mask can filter submicron particles about 80 to 90 percent as well as a surgical mask, but this data has not yet been published or replicated by other researchers. Engineers at Stanford University are investigating how to spin Styrofoam into a fine mesh that could be a proxy for the plastic filter used in N95s. Meanwhile, other researchers are exploring the possibility of sterilizing masks with heat or hydrogen peroxide vapor so that hospital workers can safely reuse them. Homemade cloth masks should be frequently boiled or washed.

Like the surgeon general, critics of universal mask wearing frequently argue that most people will not wear masks properly and may accidentally infect themselves in the process (masks should always be removed by their strings or ear loops, not by touching the contaminated front-piece). Proponents counter that any microbes caught in someone’s mask are microbes they would otherwise have inhaled and that direct evidence of harm from incorrect mask use is scant. Respiratory illnesses such as influenza and Covid-19 are primarily spread by droplets expelled from the nose and mouth. By covering these body parts, masks fight respiratory disease at its source. “To be honest, it’s common sense,” says Tang. “If you put something in front of your face, it’s going to help more than not.” If enough people wear masks at least somewhat correctly at least some of the time, the overall benefits could be dramatic. A 2011 review of high-quality studies found that among all physical interventions used against respiratory viruses—including handwashing, gloves, and social distancing—masks performed best, although a combination of strategies was still optimal.

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Masks are more than physical armor against disease—they also make us more psychologically resilient. We seem to be hardwired to incessantly touch our faces. In addition to intercepting our fingers, masks can alter our habits, teaching us not to reach for our faces in the first place. Masks further function as an important social signal. In 1919, inspired by America’s use of masks to combat influenza and eager to embrace Western modernity, Japanese health authorities began recommending that people wear masks in crowds, on public transportation, and anywhere that might pose a high risk of infection. “The nation was brought together through the mask,” which provided “a sense of control over the invisible threat of a pandemic,” writes sociologist Mitsutoshi Horii. The 2004 outbreak of avian influenza strengthened the cultural importance of masks in Japan. Habitual mask wearing became a “civic duty,” both to protect others and to take responsibility for oneself.

 

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Considering how badly the US government has botched its response to the ongoing pandemic, and how much better most Asian countries have fared so far, it’s difficult to believe that Japan once regarded America’s management of a viral outbreak as progressive. Had the US federal government listened to expert warnings about an inevitable pandemic and taken the necessary precautions years ago—by investing in domestic mask production, for instance—we would not be faced with such a dire shortage of basic medical equipment today. Mask manufacturers around the world are working overtime and expanding their operations, but it remains uncertain whether they will meet the surging demand; some of the necessary machines cost millions of dollars and take months to construct.

Even if production increases dramatically, masks must go to health care workers and patients before anyone else. N95s are especially crucial for hospital staff who perform intubations and other procedures that generate infectious aerosols. Fortunately, the available evidence suggests that for most people in most situations, an N95 is not a necessary form of protection against Covid-19. If we eventually have a surplus of surgical masks, which are much more comfortable and affordable than respirators and still provide excellent protection, they would be an ideal choice for universal masking. In the meantime, homemade masks made from tightly woven yet breathable fabric are the best option and certainly better than nothing. A piece of cloth will never be as good as a manufactured filter, but it can still smother the brunt of a cough or sneeze and impede other people’s respiratory droplets. Neighbors should form teams of tailors. Scientists should continue studying how best to disinfect and reuse masks. Engineers should reinvent the medical mask altogether, replacing disposable varieties with something more durable, sustainable, perhaps even self-sanitizing.

To overcome the present crisis we must summon more than ingenuity and industry, however. We need solidarity. As we move closer to a phase of the pandemic in which people are allowed to mingle again but there is still no vaccine—and therefore still a chance of new outbreaks—universal masking may become even more imperative. The US desperately needs to revive the ethic embodied by the legions of gauze-wrapped faces in photos from 1918. “You must wear a mask not only to protect yourself, but your children and your neighbor,” the Red Cross implored a century ago. “The man or woman or child who will not wear a mask now is a dangerous slacker.”

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