Should we unsheathe the mask?

Global CoVID-19 cases continue to rise and the world-at-large has responded. Public and private sectors alike are fighting to quell this burgeoning threat and intellectual, economic and clinical resources are aggressively being deployed. Policy directives, vaccines, protective gear and other preventative and therapeutic tools have taken immediate priority by global institutions as we tackle this unprecedented threat. However, there is one element within the global weaponry about which we have little consensus: the universal use of masks as a tool against population-scale CoVID-19 protection. Universal mask use has been treated as the silver bullet by some regions and institutions, while others have refrained from adopting them as a central element of their strategy. Though current guidelines by key frontline institutions in the global fight suggest that masks should be worn only by caregivers or the infected, the apparent success of universal mask use in quelling the CoVID-19 burden in Far Eastern nations is cause for pause, reflection and reconsideration. Should masks be given more real estate as a vital tool in the global fight?

Masks have likely contributed to the success in Far Eastern Nations

Eastern states that have successfully controlled the incidence rate of CoVID-19 infections have consistently demonstrated a history of recommending widespread use of masks. CoVID-19 responses in South Korea, Japan and Singapore – all showing promising flattening of the curve - involved the mass distribution of masks to residents. Though additional protective strategies have been implemented within these regions that may partially explain their success – such as social distancing, contact tracing – it is impossible to ignore the potential protective impact of mask use in these scenarios. Though they cannot be singularly credited for the apparent success within these regions, their consideration is warranted as a potentially (cost)-effective public health strategy, particularly given that they are relatively affordable on a unit basis. The Czech Republic has followed the Far East and has successfully subdued their incidence rate. Perhaps the rest of the West should follow suit.

Masks have been scientifically shown to reduce the transmission of respiratory viruses

Several scientific studies, both observational and randomized controlled trials alike, have confirmed the effectiveness of masks in reducing the transmission of respiratory viruses. The most convincing arbiter of the debate surrounding the utility of masks is a randomized controlled trial conducted in 2008 which concluded that masks – when worn - confer an 80% reduction in transmissibility of viral infection between patients. The results are unequivocal and an 80% risk-reduction bilaterally suggests a 96% risk-reduction on an event basis. Surely, this is likely to have a measurable and non-trivial effect on the R0 (index of viral transmissibility). Furthermore, though N95 masks have been touted as the gold-standard given their superior filtering ability, surgical masks have still been shown to offer some degree protection from the transmission of respiratory droplets. It would appear that the usage of either of these masks is better than none.

Nonetheless, several arguments have been made in opposition to the widespread use of masks. The idea that masks will not work because people will not wear them does not describe a mask problem, it describes a discipline problem. Neither does it imply that masks are in any way ineffective. On the other hand, the argument that masks should be prioritized for healthcare workers is indeed a sensible one. Healthcare workers are the most exposed collective group and our frontline soldiers must be adequately protected. However, there has not been enough consideration to the idea of both resourcing healthcare workers and the general population. Instead of shunting masks to healthcare workers and failing to acknowledge their utility in protecting the masses, we should first prioritize the resourcing of healthcare workers and then seek to resource the general population. The difference in these two perspectives is nuanced but substantial.

Masks are a relatively low-risk intervention and offer two-way protection

Another key argument made against the use of masks is the high capital expenditure when procured at scale will be expensive, particularly if disposable. It should be considered that many disposable masks were designed with the assumption of exposure to threat, and must necessarily be discarded when utilized for the purpose for which they were originally created – as a barrier to suspected exposure. However, it is impossible to deny that these are extenuating circumstances that call for resourceful (but reasonable) approaches to protocol. In the context of mass use – which describes a prophylactic scenario wherein masks are used by a largely asymptomatic population – the idea of immediate disposability must be questioned. Perhaps if adequate sanitary precautions are taken, masks can indeed be reused by healthy individuals.

Solving for disposability does not completely solve for cost. The procurement of billions of masks is, cumulatively, a considerable expense. Though resourcing populations at scale will inarguably be an costly endeavor, it should be recalled that masks protect both contamination and exposure of infection, and even if expensive at scale, the economic mutilation that will occur if the pandemic grows unchecked is far more costly.

We should strongly consider the value of universal use of masks, particularly for regions with rapid and unchecked caseload growth

We are invited to engage in sober, dispassionate reflection on the utility of universal mask use in this fight. In addition to the low-risk nature of this intervention, the anecdotal and scientific evidence supporting their use is cause for consideration. Particularly for areas that are being ravaged by CoVID-19 infection – the adoption of masks may be a reasonable, intelligent and low-risk intervention to add to our arsenal of effective protective practices. We should all wash our hands, practice social distancing and reduce interpersonal contact – but perhaps we could flatten the curve faster if we were to wear masks as well.

Author: Dr. David Walcott

M.D. || Ph. D. || MSc. (Immunology) || INSEAD ECA Fellow

*Primary references available on request