Masks: Now more than Ever

Recent studies and models argue that the humble, low-tech face mask, if worn by enough people, is the most powerful defense we have against the pandemic. So powerful, in fact, that mask-wearing could save us from our shocking national unreadiness to deploy an effective Test, Trace, and Quarantine program as we emerge from lockdown.

The United States missed a chance to suppress the SARS Cov-2 virus in the early stages after its arrival here, and we’ve paid a high price, measured in tens of thousands of lives lost, thousands more disabled, and crushing blows delivered to our economy and to our standing in the world. Though far from perfect, the state-by-state lockdowns of varying intensity still prevented the COVID-19 toll from becoming far worse. Losing 120,000 people (and probably more than double that by election day) is nothing to celebrate, but losing a million or two would have been catastrophically worse. However, our erratic response left us on a knife edge: the number of confirmed new cases has plateaued at far too high a level—over 20,000/day nationally—and is likely to begin climbing again as people try desperately to live like we used to. The virus will grow exponentially given the chance, so the growth curve could accelerate upward quickly as states relax restrictions on social contact. What should we do?

It Was a Lovely Plan

In the first weeks of this pandemic, as the virus revealed just how dangerous it was, a standard plan for resisting it emerged:

• Phase I would see a rapid and thorough shutdown of human contact: stop travelling, stop going to work, stop socializing, just stop. The goal was to disrupt the virus’ exponential rate of reproduction, protect the healthcare system as much as possible from disastrous overload, and buy time to put better responses in place.
• Phase II would roll out those better responses after the virus population had been relatively contained. In it, we’d institute a large-scale system of testing, tracing, and quarantine, in order to tamp down outbreaks quickly, and enable economies to begin to reopen. In Phase II, we would remain on a steep learning curve, and roll out refinements to protocols as our understanding improved. Economic and social activities would come back to life in cautious steps, though in most cases not all the way back.
• Phase III, probably overlapping with Phase II, would add the deployment of pharmaceutical assists: antiviral cocktails, immune system modulators, partial vaccines and, just maybe, a “complete” vaccine, able to provide complete protection over an extended period of time. With or without a complete vaccine, Phases II and III would see us gain better and better control of the virus, with a tolerably low rate of infection and a bearable rate of death. Note that in a country of 330 million people, where nearly 3 million die annually of all causes, a bearable rate can be a pretty big number: we are “used to” the tens of thousands who die annually in vehicular mishaps, the tens of thousands more who die of opioid overdoses, suicide, shootings, and other non-diseases and, of course, the millions who die of heart disease, cancer, and other diseases. If COVID-19 ends up killing 100,000 or 200,000 a year, we’ll get used to it, somehow, until we figure out how to drive it down.

Some countries aced Phase I: Australia, New Zealand, South Korea, Japan, and Uruguay, plus several more, have kept COVID-19 deaths between 4 and 8 per million population, with new deaths at or near zero/day.  The United States, unfortunately did not ace the test: our COVID-19 deaths are up to nearly 350 per million population, and climbing, with nearly a thousand new deaths/day. Nevertheless, in an “eat dessert first” mindset, we have skipped the part about getting virus levels very low, and moved on to widespread socioeconomic reopening. Some states are being more careful than others, but the more careful states are vulnerable to the choices made in their less careful neighbors.  Some states are working hard to get test, trace, and quarantine infrastructure up and running, while others are all but giving up on it.

As a result of our scattershot approach and Donald Trump’s desire to persuade his base that the epidemic is almost over, we are stumbling into Phase II in bad shape—much worse than most other large countries. By sabotaging the federal response, Trump has also impaired response at other levels of government. If we’re going to get past this virus, we’re going to have to do a lot of the heavy lifting together, from the bottom up. Can we? What will it take?

Test, Trace, Quarantine

Ever since the virus began to spread, scientists have been furiously working to determine which responses were the most useful.  Early on, they learned that “super-spreader” people and events accounted for a surprising share of the virus’ spread—there’s some version of an 80:20 rule in effect. There’s also a 20-40 rule: that’s the age range of most super-spreaders. In response to this discovery, they prioritized the Test, Trace, Quarantine model, which can be very effective when there’s a lot of resources applied to a limited number of outbreaks. All of those countries mentioned above with incredibly low numbers of cases and deaths adopted early and aggressive TTQ.  The problem for the US is that our country is far larger, more diverse, and more polarized than any of those, with an administration hostile to the idea, and a “you’re not the boss of me” culture that doesn’t cotton to a swab up the nose.  TTQ is being rolled out in the more progressive states, but at fraction of the level required to make it work as well as it does in Australia, New Zealand, South Korea, Japan, and Uruguay. TTQ is going to help, but it’s not ready to take over from the original lockdown as our front-line defense.

Masking for a Friend

As scientists learn more about what’s working and what isn’t, some are beginning to believe that the efficacy of mask-wearing was originally underestimated. Or, more specifically, that a high degree of public mask-wearing might be surprisingly effective. Instead of herd immunity, we might be able to create worn immunity. This hunch got a boost last week when a team of well-regarded modelers in the UK tested the idea, running models will all sorts of different assumptions about the effectiveness of masks and the proportion of people wearing them.  

Their top line conclusion is that if a very high proportion of the population “masks up” when interacting with other people (at least 75%, ideally close to 100%), along with the usual checklist of social distancing behaviors, the virus’ reproduction rate can be reduced to below 1.0, even without a full TTQ implementation. This is true even if the masks are not perfectly effective. Even in the absence of enough TTQ, there’s a chance that we can save ourselves from ourselves with enough masking. If true, this is a welcome surprise. It’s also one that can be executed from the bottom up.

Our challenge is to persuade ourselves and most everybody else to embrace the habit of slipping a mask on to deal with people outside our immediate safe circles, and keep doing it for months that may stretch into a few years. If we make this our baseline, we may be able to cut the cases and therefore deaths and disabilities substantially, and let the economy rebuild. As this happens, TTQ can catch up and start sniffing out and snuffing out the super-spreader events, making it easier to keep the virus down, and lowering the risk of contagion still further. As pharmaceuticals come online, they will build on the strong foundation built by masking, and get us closer still to a new normal life that’s pretty livable. A life, even, where masks are ever-more-lightly used, and the best end up in the Smithsonian.

Given that lots of people are, at this very moment, eager to be mask-free, how can we persuade them to do an about face about their face and re-mask it?  It seems that there are five avenues available to us:

1. Improve mask ergonomics
2. Embrace and extend masks as identity statements
3. Shift social norms
4. Provide legal encouragement where needed
5. Clarify mask etiquette

Here are a few words about each:

1. Mask Ergonomics. Make them more comfortable to wear, easier to put on and take off, easier to tuck in a pocket, easier to breathe through, easier to clean. Make special-purpose masks for different activities, from athletics to farming to the factory floor. Make good masks for children of all ages. A Nobel prize to the designer of one that works for high platform divers.
2. Masks as identity statements. This whole idea won’t work if masks remain a polarizing  “statement” for or against Trump, so turn them into yard signs for everybody. Trump2020 masks. Biden2020 masks. Masks for the people running for dog-catcher. Campaigns at every level should give them out. Celebrities should wear them. Actors should wear them on screen and on stage in new material written to accommodate that. Animated characters should wear them. Athletes should wear them in the game, and in after-game press conferences. Characters in advertising should wear them. Stand-up comics. Reality TV contestants. Porn stars (don’t try to figure this one out). It’s a huge opportunity for brands to offer them as logo-wear: Harley Davidson, John Deere, Caterpillar, Alaska Airlines, Nordstrom, Apple, Google, Microsoft. Every professional sports team should have logo masks (the NFL is there already), including masks that match the names/numbers of big stars. What’s cooler, a Russell Wilson mask or a Bobby Wagner mask? Every school at every level should have logo masks. Fashion designers should incorporate them into ensembles: matching mask-and-scarf, mask-and-hat, mask-and-swimsuit, mask-and-shoes, etc. There should be slogan masks, funny masks, over-the-top masks, masks of your own face, business formal masks and business casual masks, and masks as part of workwear for construction sites, airplane factories, commercial fishing vessels, warehouses, and strawberry fields forever. If you doubt the market for all this, google “Steampunk Plague Doctor Mask” and stand back.
3. Social norms. Wearing a mask should be evidence of care for others, of wearing one for the team, of being a good person, a good citizen, a good friend. Not wearing one under appropriate circumstances should feel uncomfortable. Masking for a friend should be a new norm, a shared experience. They should be generously distributed to anyone who is tight on time or money to acquire masks for themselves.
4. Legal encouragement. This, as the wicked witch of the west said, requires delicacy. The goal is to have every venue that concentrates people, from the corner Starbucks to Husky Stadium, require that people wear masks to get in, and keep them on once there. They may want the state to pass a law “making them do it,” so they don’t have to fear losing customers to competitors by choosing to do it unilaterally.
5. Etiquette. Obviously, there’s no point in wearing a mask when you’re home alone. So there needs to be an etiquette of when to slip it on, and when it’s OK to slip it off. There’s no reason to expect people to put up with wearing masks when it’s pointless; that’s just counter-productive. It’s really important to be sure that people have shared standards about when to wear and when to go bare; that’s etiquette.

Masks aren’t a magic bullet, nor do they replace all the other risk-reducing measures we need to take as individuals and organizations, but given the urgent need to keep the virus down and the unreliability and uncertainty that surround solutions that require top-down implementation in our country with a crazy top, it’s worth making a huge effort to make ourselves a mask culture for a while. Wear your heart on your face.

Further reading:

https://royalsocietypublishing.org/doi/10.1098/rspa.2020.0376

https://www.washingtonpost.com/opinions/face-masks-are-vital-to-stopping-the-spread-of-the-virus-wear-one/2020/06/15/c2e687fe-af34-11ea-856d-5054296735e5_story.html

https://slate.com/news-and-politics/2020/04/why-americans-resist-coronavirus-masks.html