It seems odd that there has been no clear and unequivocal advice about whether or not it would help if we all wore face masks. This piece considers the many different aspects of the question which, between them, explain its complexity and why there has not yet been a single clear recommendation. Instead the matter has been left to individuals to decide.
This organic approach to an issue in which every one of us is potentially involved has at least two advantages. It lets the authorities off the hook of accountability for any sort of uniform advice. And it cedes responsibility to the people, which is widely considered a desirable principle. But if and when there is a clear technical (health or clinical) case for a particular protocol relating to masks, it will be an important challenge for the authorities to spread the word and obtain widespread community compliance.
School closures
Two weeks ago the question of whether or not schools should be closed seemed to be the most critical on which there was no clear advice. The experts had discussed the matter. We were told that schools would remain open but it would be good if parents who were able to do so would keep their kids at home.
The solidarity of the National Cabinet seemed to be fractured. Different jurisdictions provided different advice, based not just on medical views but on logistical matters such as when school terms were ending. Very soon it became apparent that the matter was apparently too complex for uniform national action to be agreed and it fell to parents to bear responsibility for the decision.
This cannot be seen necessarily as a criticism or failure of ‘the powers that be’. It may well be that the mixed mode that emerged about schools was in fact optimal given all the relevant circumstances and considerations.
The characteristics of that decision on schools which made it so complex seem now to relate to the question of whether or not to recommend or potentially even to mandate the wearing of masks. Is it to be Tonto or the Lone Ranger?[1]
Aspects of the question
Where the wearing of masks is concerned, the aspects to be considered include the following.
1. Does the wearing of masks reduce rates of transmission? This might appear to be the simplest and most important question but, even without scientific knowledge, one can understand its complexity. It obviously depends on the number, type and location of mask deployed. Does the effectiveness of masks depend on the proportion of the population who wear them? Why does the evidence from other countries seem to be conflicting? One thing that is clear is that masks are effective only when used in combination with other measures, most particularly frequent hand-washing with soap and water. The efficacy of masks is impacted by their supply; in short supply, the risks multiply of having them used in an unhygienic fashion.
2. Does the wearing of masks have desirable or undesirable effect on the extent to which the population, or particular groups within the population, are compliant with critical measures like self-isolating and social-distancing? Some have argued that people wearing masks, or seeing others wear them, instils over-confidence and a lack of the required discipline on other fronts. The widespread use of masks could conceivably increase the public’s pessimism and propensity for ‘catastrophisation’. This could have adverse effects for mental well-being.
3. There is clearly a hierarchy of need relating to the wearing of masks and other personal protective equipment. Clinicians and others ‘on the frontline’ must be given first dibs, both for their own safety and for the effectiveness of the health and related systems. Any increase in the encouragement of others in the population to wear masks would therefore have to be moderated by accurate knowledge about the supply of masks.
4. “A mask is not a mask.” All sorts of products exist, including surgical masks and cloth or fabric face coverings. Surgical masks and respirators are essential for practitioners dealing with COVID-19 patients and those suspected of having it. Even if a uniform decision was possible on other fronts, there would be questions about what types of mask is useful in particular circumstances. We have seen and heard much about ingenuity of individual people and retooled companies making masks, but the efficacy of various models and their uses has to be considered.
5. Consideration needs to be given to the cultural aspects of wearing masks. In Australia we look to countries to our north to see community/political entities (Singapore and the like) which are more accustomed both to wearing masks and to being told what to do on such matters. To the rugged individualists we are supposed to be, being told to wear masks may be a bridge too far, jeopardising a national consensus.
6. Some will argue that the question of mandating the wearing of masks is a legitimate battleground on the ‘personal freedom v. government control’ front.
7. There may be implications relating to the effect of a uniform approach on particular subgroups of the population. If wearing masks has cost indications not covered by governments, mandating their wearing would contribute to further inequality between rich and poor, employed and unemployed. The same might be said for urban-rural differences and equity. If there are national shortages of masks and other personal protective equipment they are certain to be greater and to have more impact in rural and remote areas than in the major cities.
8. Wearing a mask needs to be done properly. Any mandatory use of masks would need to be accompanied by detailed practical advice about what to do before putting it on, when to change it, how take it off and how to discard it. The WHO and many other organisations provide essential information about such matters which should be consulted by potential users. There is a recent article on the issue at https://insidestory.org.au/so-you-want-to-wear-a-mask-in-public/
It might be that, in their wisdom, governments and their advisers have tacitly agreed that it would be best if the decision about wearing masks remained organic – something to be owned and narrated by the community itself, evolving at the pace determined by people themselves. This would have some of the characteristics of the responses to the COVID-19 situation advocated by those who trust in citizen engagement and community development. I belong to that group but also crave information and advice from technicians about matters that can be subject to technical certainty.
And the Lone Ranger? Every week after he and his trusty friend Tonto had saved the world in 30 minutes, they would ride off into the distance, silhouetted against the skyline. Someone turns to the sheriff to ask who that masked man was. The sheriff responds that it was the Lone Ranger, who is then heard yelling “Hi-Yo Silver, away!” as he and Tonto ride away. We could do with him back again.
Information and disclaimer: this article has been written in the belief that policies relating to the wearing of masks are complex and illustrative of the great difficulties posed for decision makers by the current COVID-19 situation. It is not my intention to make or promote judgements about the clinical, social or economic aspects of the matter and it is certainly not my intention to provide advice to individuals. There is a mass of information online about the wearing of masks in the current situation and people making a personal decision should consider that information.
Some circumstances make the wearing of a mask essential. They include the situation in which a patient is suspected of having infection or when someone is coughing or sneezing such that a physical barrier between them and another is of obvious value. But based on the majority views in Australia at present it seems that in other circumstances most people will not benefit from wearing a surgical mask.
General practitioners should be able to access surgical masks through their local Primary Health Network.
For the latest advice, information and resources, go to www.health.gov.au
The National Coronavirus Health
Information Line on 1800 020 080 operates 24 hours a day, seven days a week. If
you require translating or interpreting services, call 131 450.
[1] Those of you old enough to get this joke are hopefully self-isolating at home and getting your grandchildren to drop groceries at the door.