W.H. Kellogg, M.D., infectious diseases expert and then-executive officer of the California State Board of Health, made this rueful, brutally honest 1920 observation on the failure of masking to contain rampant influenza spread during the devastating 1918 influenza pandemic:
The masks, contrary to expectation, were worn cheerfully and universally, and also, contrary to expectation of what should follow under such circumstances, no effect on the epidemic curve was to be seen. Something was plainly wrong with our hypotheses.
A century later, plus ça change, plus c’est la même chose – the more things change, the more they stay the same.
The current much less lethal coronavirus COVID-19 epidemic (i.e., 100-1,000X lower death rate than the 1918 pandemic flu) is clearly waning. The Centers for Disease Control and Prevention (CDC) is poised to declare its epidemic phase over after 10 consecutive weeks of declining COVID-19 mortality, which has markedly reduced the virus’ U.S. weekly death toll. Despite these hard, objective outcome data, recent bipartisan, coercive admonitions for compulsory masking have been pronounced by Democratic Party presidential candidate Joe Biden, Speaker of the House Nancy Pelosi (D-Calif.), and Republican Texas Gov. Greg Abbott.
Today’s hectoring rhetoric and accompanying national, state, or local mandates notwithstanding, 100 years after Dr. Kellogg’s frank lament, there is still no controlled evidence that supports masking, especially in non-health-care settings, to attenuate the epidemic spread of respiratory viruses, including COVID-19.
A controlled study reported in “Nature Medicine,” April 3, 2020, indicated that properly fitted surgical face masks might reduce human non-COVID-19, cold-causing coronavirus emission into exhaled aerosols and large respiratory droplets, among patients acutely ill with respiratory infections. However, these investigators also noted that in samples collected from those comparably ill patients randomly allocated to the group not wearing masks, “the majority of participants with influenza virus and coronavirus infection did not shed detectable virus in respiratory droplets or aerosols.” Furthermore, viral “shedders” transmitted small amounts of virus, and the authors suggested that “prolonged close contact would be required for transmission to occur, even if transmission was primarily via aerosols, as has been described for rhinovirus [i.e., common] colds.”
These limited, immediate-term experimental observations — equivocal at best — provide no rational, evidence-based justification for daily, prolonged mask usage by the general public to prevent infection with COVID-19. Moreover, a subsequent pooled (so-called “meta-“) analysis of ten controlled trials assessing extended, real-world, non-health-care-setting mask usage revealed that masking did not reduce the rate of laboratory-proven infections with the respiratory virus influenza. The findings from this unique report — published May 2020 by the CDC’s own “house journal” “Emerging Infectious Diseases” — are directly germane to the question of masking to prevent COVID-19 infection and merit some elaboration.
Ten randomized, controlled trials reporting estimates of face mask effectiveness in lowering rates of laboratory-confirmed influenza within the community, published between 2008 and 2016, were analyzed and pooled, applying a rigorous, standardized methodology. One study evaluated mask usage by Hajj pilgrims to Mecca, two university-setting studies assessed the efficacy of face masks for prevention of confirmed influenza among student campus residents over five months of surveillance, and seven household studies examined the impact of masking infected persons only (one), household contacts of infected persons only (one), or both groups (five). None of these studies, individually, or their aggregated, pooled analysis, which enhanced the overall “statistical power” to detect smaller effects, demonstrated a significant benefit of masking for the reduction of confirmed influenza infection (also see tabulation). The authors further concluded with a caution that using face masks improperly might “increase the risk for (viral) transmission.”
Washington state’s June 24 government-mandated public masking edict for the alleged prevention of COVID-19 infections was immediately challenged in a court with statewide jurisdiction. Although the plaintiffs failed to cite the May 2020 meta-analysis discussed above, they did refer to an April 2020 “New England Journal of Medicine” (NEJM) commentary on masking to support their claim of “scant evidence” that mask-wearing “does anything to reduce transmission of COVID-19.” Indeed, the NEJM citation provided was extracted in the legal filing, verbatim:
We know that wearing a mask outside health care facilities offers little, if any, protection from infection. Public health authorities define a significant exposure to COVID-19 as face-to-face contact within six feet with a patient with symptomatic COVID-19 that is sustained for at least a few minutes (and some say more than 10 minutes or even 30 minutes). The chance of catching COVID-19 from a passing interaction in a public space is therefore minimal. In many cases, the desire for widespread masking is a reflexive reaction to anxiety over the pandemic.
Most importantly, the plaintiffs stressed how this arbitrary, evidence-free mandate, which requires “Every person in Washington state [to] wear a face covering that covers their nose and mouth when in any indoor or outdoor public setting,” is “invasive” and “coercive,” concluding:
… by requiring them [plaintiffs] to wear face masks the government is essentially compelling them to support [WA] Gov. Jay Inslee’s position on a matter subject to controversial public debate in violation of their freedom of conscience. The Washington State Constitution prohibits compelling individuals to speak against their conscience. Further, the citizens say wearing masks has now become a ‘virtue signal’ rather than a real safety precaution. Compelling free individuals to wear face masks forces them to espouse support for the scientifically unsupported lockdown measures and the draconian government intrusion into citizens’ daily lives.
Dr. D.A. Henderson (1928-2016) was an indefatigable, iconic public health steward who spearheaded the successful global campaign to eradicate a genuine plague, variola virus: smallpox. Henderson’s salient observations from a 2006 review provide a cogent rebuttal to the prevailing totalitarian imposition of irrational lockdowns and masking edicts to ostensibly “combat” COVID-19.
There are no historical observations or scientific studies that support the confinement by quarantine of groups of possibly infected people for extended periods in order to slow the spread of influenza. …
It is difficult to identify circumstances in the past half-century when large-scale quarantine has been effectively used in the control of any disease. The negative consequences of large-scale quarantine are so extreme (forced confinement of sick people with the well; complete restriction of movement of large populations; difficulty in getting critical supplies, medicines, and food to people inside the quarantine zone) that this mitigation measure should be eliminated from serious consideration. …
Home quarantine also raises ethical questions. …
In Asia during the SARS period [a coronavirus like COVID-19, which caused localized Asian outbreaks during 2002-2003], many people in the affected communities wore surgical masks when in public. But studies have shown that the ordinary surgical mask does little to prevent inhalation of small droplets bearing influenza virus. The pores in the mask become blocked by moisture from breathing, and the air stream simply diverts around the mask. There are few data available to support the efficacy of N95 or surgical masks outside a healthcare setting. N95 masks need to be fit-tested to be efficacious and are uncomfortable to wear for more than an hour or two.
Henderson concluded with this sober warning:
The problems in implementing such measures are formidable, and secondary effects of absenteeism and community disruption as well as possible adverse consequences, such as loss of public trust in government and stigmatization of quarantined people and groups, are likely to be considerable. …
Experience has shown that communities faced with epidemics or other adverse events respond best and with the least anxiety when the normal social functioning of the community is least disrupted. Strong political and public health leadership to provide reassurance and to ensure that needed medical care services are provided are critical elements. If either is seen to be less than optimal, a manageable epidemic could move toward catastrophe.
Hope springs eternal that the rational, caring public health mindset advocated by Dr. Henderson will re-emerge “unmasked” and be applied, if belatedly, to the management of COVID-19.
Andrew Bostom, M.D., M.S., is an associate professor of family medicine (research) at the Warren Alpert Medical School of Brown University. Dr. Bostom is a trained clinician, epidemiologist, and clinical trialist.