Where Have All The Masks Gone?

Masks are back in the limelight as Covid-19 cases rise, kids return to school and first lady Jill Biden has another Covid infection.

In a recent post, I explained that the CDC’s Healthcare Infection Control Practices Advisory Committee proposed watering down infection-control precautions. One especially worrisome assertion was that plain, loose-fitting surgical masks are equivalent in providing protection to N95s. They are not.

Their plan received considerable pushback, especially over the lack of transparency in the process, concern over HICPAC biases and lack of responsiveness from CDC director Mandy Cohen. Particularly concerning were stories that patients were afraid to go to appointments because they risked becoming infected while seeking care due to healthcare workers refusing to mask.

In November 2020, Cohen tweeted, “Masks work. When worn over your mouth and nose, a mask is the best thing we can do to slow viral spread. It costs so little, but is worth so much.”

On February 24, 2022, president Biden’s polling firm, Impact Research, sent a memo urging him to declare victory against Covid-19 and to stop talking about restrictions.

Since then, we have repeatedly heard that the pandemic is over and, as Cohen said last week, “We’re in a much different and better place … We have vaccines, at-home tests, effective treatments, and we have common sense strategies like washing your hands and staying away from people when you are sick.” Not once did she utter the words “mask,” “aerosol,” or “ventilation,” which are the most effective strategies against Covid. She broadcast this despite noting that up to 10,000 people were hospitalized with Covid-19 during a one-week period.

The reaction on social media was swift and scathing:

Gregg Gonsalves, a public health expert at Yale, elaborated his criticism via email: “The Biden administration has made a political choice—not a scientific or public health one—to downgrade the national response to COVID-19. Included in this is the reticence or outright avoidance of mentioning masking even as cases rise in the US. The CDC director, in talking about this late increase in COVID cases, bends over backward to mention hand-washing, but not N95s. Without question, N95s offer individuals protection against infection and leaving out that fact is a disservice and an abdication of duty.”

“The CDC is dominated by for-profit hospitals,” said Jose Luis Jimenez, professor of chemistry at the University of Colorado. “Airborne precautions are very expensive,” so just use surgical masks now. Jimenez and others have also decried that “expert” committees like HICPAC are appointed by the CDC to report back to the CDC and are comprised of people who share similar viewpoints. For example, there are no aerosol experts on the committee.

Many hospitals dropped their masking requirements after Biden declared the public health emergency over. Once that happened, most people stopped masking. One physician said, “We weren’t told to mask, so people don’t. People do what the policy is—and there is no policy now.” She only occasionally sees surgical masks being worn, and rarely an N95, because of peer pressure. She added that she regularly sees hospital-acquired Covid-19 and that many people come to work while ill.

Several people told me they are avoiding care because they are afraid of getting Covid-19 in the hospital. They are especially angered that some healthcare workers refuse to mask, even when requested to do so. These patients believe this is a violation of the Americans with Disabilities Act. Pantea Javidan, J.D., Ph.D., a Stanford sociologist, concurs, noting, “A person with a disability who is at increased risk from COVID-19 can reasonably expect their healthcare providers to wear masks as an accommodation to mitigate potential infection risks. The ADA mandates that accommodations be provided unless it presents an undue hardship to the provider. In the current context of the pandemic, it would be challenging for healthcare providers to assert that wearing a mask imposes undue hardship.”

In May, the Mass General Brigham policy told patients, “No. You cannot ask staff members to wear a mask because our policies no longer require it.” It was changed to say, “Patients can ask, but providers determine when and if masking in a particular situation is clinically necessary.” I reached out to Dr. Erica Shenoy, chief of infection control at MGB, asking if she was “the main author of the policy which allows healthcare workers to refuse requests from patients to mask.

“Also, can you please clarify what the rationale for that is?” I asked. “Doesn’t that fall under the need to provide reasonable accommodations for patients? Isn’t aerosol transmission the primary route for Covid?”

Instead, I received a response from a spokesperson that did not answer those questions but said, “There is no policy allowing healthcare workers to refuse requests from patients to mask.”

Asked about the ethics of dropping masking requirements in hospitals and nursing homes, Dr. Art Caplan, professor of medical ethics at New York University’s Grossman School of Medicine, didn’t hesitate to declare it “utterly, completely, irresponsible.” He noted, “You’re frequently around vulnerable people,” and “The evidence is that masking is successful in environments like hospitals and nursing homes.”

Some medical staff now claim it is their “right” to choose not to mask. Caplan stressed that this is a moral issue, not one of “freedom” for healthcare workers. Citing codes of ethics, he added, “The first principle is, you must do what is in the best interest of your patient. It is not ‘You must do what you think is best for you.’” I was taught that the first principle of medicine is, “Do no harm.” The refusal by healthcare workers to mask, especially when asked to do so by a patient, contravenes that principle.

The CDC and local governments are no longer collecting or reporting reliable, timely data about Covid-19 infections. Many have dropped from daily reporting to weekly, and now only monthly. Wastewater levels are our best indicator, but only available in some areas. On Sept 1, CNN reported, “Data from Biobot Analytics, a biotechnology firm that has partnered with the CDC, shows that wastewater concentrations of the coronavirus are similar to what they were at the start of the first winter surge in 2020.” Hospital admissions doubled over the past month, and positive tests tripled in the past two.

Given all these factors and that even asymptomatic people can transmit Covid-19, it makes zero sense for hospitals, nursing homes and other healthcare facilities to eliminate masking. We’ll find out in November if HICPAC has heard the public outcry in response to its plans.