Why masks work, but mandates don’t

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Covid cases and hospitalizations are on the rise again in the US, and the number of deaths is also starting to increase. In response, many people are understandably asking what the country can do to minimize the toll of the virus in the coming weeks.

So far, there has been a lot of discussion about mask mandates. schools in Philadelphia; Providence, R.I.; Berkeley, California; and Brookline, Mass., have reset theirs, as well as several colleges. Elsewhere, some people are frustrated that officials like New York City Mayor Eric Adams have failed to do so.

Critics have accused these leaders of a lack of political courage, saying they are giving in to Covid fatigue rather than imposing necessary public health measures. But I think the criticism is misinterpreting both public health history and the recent scientific evidence about mask mandates.

The evidence suggests that broad mask mandates have not done much to reduce the Covid caseload in the past two years. Today, masking rules may do even less than in the past, given the contagiousness of current versions of the virus. And successful public health campaigns are rarely divided over a measure that is unlikely to make a big difference.

From the beginning of the pandemic, there has been a paradox with masks. Like dr. Shira Doron, an epidemiologist at Tufts Medical Center, puts it“It’s also true that masks work and mask mandates don’t work.”

To start with the first half of the paradox, masks reduce the spread of the Covid virus by preventing virus particles from one person’s nose or mouth from going into the air and infecting another. Laboratory studies have repeatedly shown the effect.

Given this, you would think that communities where mask-wearing is more common would have had far fewer Covid infections. But that has not been the case.

In US cities where mask use is more common, Covid has spread at a similar rate to mask-proof cities. Mask mandates in schools also seem to have done little to reduce the spread. Hong Kong, despite the almost universal wearing of masks, has recently endured one of the world’s worst Covid outbreaks.

Proponents of mandates sometimes argue that they have a large effect, even if not apparent in population-wide data, due to the number of other factors at play. But this argument does not seem convincing.

After all, the effect of vaccines on serious diseases is abundantly clear in the geographic data: places with higher vaccination rates have suffered far fewer Covid deaths. The patterns are clear, even if the world is a messy place, with many factors other than vaccines influencing Covid death rates.

But when you look at the data on mask wear — both before vaccines were available and after, as well as both in the US and abroad — you struggle to see patterns.

The idea that masks work better than mask mandates seems to defy logic. It reverses an idea associated with Aristotle’s writings: that the whole must be more than the sum of its parts, not less.

The main explanation seems to be that the exceptions often matter more than the rule. The Covid virus is so contagious that it can spread in short periods of time when people take off their masks, even if there is a mandate.

Airline passengers take off their masks to have a drink. Restaurant goers go maskless as soon as they walk through the door. School children let their masks slide off their faces. So do adults: Research from the University of Minnesota shows that between 25 and 30 percent of Americans consistently wear their masks under their noses.

“Although masks work, getting millions of people to wear them and wear them consistently and correctly is a much more challenging task,” writes Steven Salzberg, a biostatistician at Johns Hopkins University. Part of the problem, Salzberg explains, is that the most effective masks are also less comfortable. They cover a larger area of ​​a person’s face, fit better and restrict the flow of more air particles.

During an acute crisis – such as the early months of Covid, when masks were one of the few forms of protection available – strict guidelines can still make sense. Public health officials may urge people to wear high-quality, close-fitting masks and almost never take them off in public. If the mandate has even a modest benefit, it may be worth it.

But this approach is not sustainable for many years. Masks hinder communication, lack glasses and can be uncomfortable. It is not for nothing that children and air passengers burst into applause when they hear that they can take off their masks.

In the current phase of the pandemic, there are fewer divisive measures that are more effective than mask mandates. Booster shots are widely available. A drug that can further protect the immunocompromised, known as Evusheld, is increasingly available. So are treatments after infection, such as Paxlovid, which make Covid less severe.

(For young children, who are not yet eligible for the vaccine, Covid is overwhelmingly mild, comparable in severity to flu.)

Continuing to expand access to these treatments could do more to reduce hospitalizations and deaths from Covid than any mask rule likely would. “People have the means to protect themselves,” Dr. Robert Wachter, chair of the division of medicine at the University of California, San Francisco, told me. Without a much larger increase in Covid hospitalizations, he added, the case for mandates is weaker than it used to be.

dr. Aaron Carroll, the chief health officer of Indiana University, recently wrote for the opinion section of The Times: “Instead of bickering about things that are hopelessly politicized, like mask mandates, those in public health could focus on efforts that would can make more of a difference.”

The available data also suggests that more than half of Americans have had Covid in the past six months, making it unlikely that many of them will now get it again. As Jennifer Nuzzo, an epidemiologist at Brown University, told Vox, “A lot of the people who don’t wear masks have already had Covid, so they say, ‘I’ve been vaccinated, I’ve had it — how long? do you want me to do this?’ And it’s kind of hard to say, ‘No, you absolutely have to wear it.’”

The country will probably never come to a consensus on masks. They have become yet another source of political polarization. Democrats are more likely to wear masks than Republicans, and Democrats who identify as “very liberal” are more likely to support mandates.

Fortunately, the scientific evidence points to a reasonable compromise. Because masks work and mandates often don’t, people can make their own decisions. Anyone who wants to wear a high-quality, close-fitting mask can do so and is less likely to contract Covid.

That approach — one-way masking — is at least consistent with what hospitals have long been doing, as Doron, Tufts’ epidemiologist, points out. Patients, including those who are sick with infectious diseases, usually have not worn masks, but doctors and nurses have. “One-way masking is how we’ve always used them,” she wrote.

The same system could work outside of hospitals for Covid. For example, Wachter believes the time for mandates is over, but still wears one at the grocery store, in classrooms, on airplanes, and elsewhere. Different people can reasonably make different choices.

A weekly immigrant takeout program called United We Eat @Home has made Ghalia Ahmad Fayez AlMasri a local celebrity in Missoula, Mont. “When I cook, my meal goes very, very quickly — 15 minutes this time,” AlMasri, who fled Syria in 2017, told The Times.

The program has helped refugees apply for farmers’ market permits and find restaurant jobs. And it has diversified the city’s food scene: without it, there would be no place for Missoulians to order Congolese, Pakistani, or Guinean food. Here’s more about the program, as well as mouthwatering photos.





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