Changing our approach towards mask use

“A stream of fresh evidence has emerged on widespread mask adherence helping to reduce community spread, resume economic activity, and tide over the crisis without needing a total lockdown.” Workers at a wholesale iron market in Kolkata. Reuters

“A stream of fresh evidence has emerged on widespread mask adherence helping to reduce community spread, resume economic activity, and tide over the crisis without needing a total lockdown.” Workers at a wholesale iron market in Kolkata. Reuters  

It is unfortunate that the population-level significance of masks is still not fully appreciated

Lately, a series of studies has provided evidence that widespread mask use can help reduce the spread of COVID-19 and considerably slow the pandemic. With world opinion coming round in favour of mask use, early this month the World Health Organization (WHO) adopted a slightly more favourable position towards widespread mask use than earlier. India’s initial scepticism towards widespread mask use continues to linger at a time when this simple public health intervention is more crucial than before.

Conventional wisdom

Evidence forms the substratum of the scientific approach. In emergencies, however, demand for hard evidence can prove painful — and it is indirect evidence and conventional wisdom that often guide preliminary responses. It is such indirect evidence and conventional wisdom that inspired far-reaching measures like nationwide lockdowns, at least in the early days of the pandemic. The same, however, failed when it came to making masks ubiquitous early on, except for nearly half a dozen small nations which had done so by the end of March. This looks all the more surprising given that there existed a range of legitimate reasons to back such a decision: available evidence on mask use from similar other respiratory infections; the implication of large droplets in COVID-19 spread; the possibility of pre-symptomatic and asymptomatic transmission; pervasiveness of contexts that are unconducive to mass quarantine; and the far more benign nature of widespread masking than lockdowns.

Watch | Dos and don'ts of wearing masks

The WHO’s position on masks is an apt case in point. The WHO’s own NPI (non-pharmaceutical interventions) guidance on pandemic influenza recommends mask use for the public during severe pandemics. The WHO’s harping on hard evidence and an overly circumspect approach towards widespread masking in its April advisory came at a time when the virus was rampaging through dozens of countries. The global deepening of the pandemic today has been able to attract only paltry concessions in this attitude. This is apparent in the WHO’s June advisory on masks. It has treated widespread masking like some potentially unsafe therapeutic agent which requires very careful weighing of risks and benefits. Also, its enumeration of potential risks and disadvantages of public masking served to severely underplay the overall benefit that could accrue from it. Another counter-intuitive aspect is the organisation’s fixation on ‘healthy’ individuals while contemplating ‘public’ masking. Social/physical distancing is prescribed for everyone without reservation since inapparent carriers can also spread infection. However, community-wide mask use is dismissed citing lack of evidence on masking healthy persons — disregarding the fact that it includes masking inapparent carriers too.

Perhaps what is most unfortunate is that a useful mass-level measure was reduced to a predominantly personal protection measure. Early recommendations on masks predominantly involved using them to protect either health workers or high-risk individuals. This, along with scepticism towards widespread mask use, has nourished an approach that continues to underrate the ability of masks to deliver significant population-level results, like slowing down the pandemic across a whole geography and doing away with the need for a complete lockdown. And it is such an approach that still characterises India’s mask use policy.

Watch | Coronavirus: Can masks protect you?

One may say that India ‘copied’ its first lockdown from other nations, but lockdowns in no part of the globe were driven by robust evidence either. What is disappointing is that local, contextual thinking was diluted. When India declared the lockdown on March 24, there were few other nations under lockdown whose social demographic features warranted widespread mask use more than India’s did. The Ministry of Health advisory on widespread use of home-made masks came on April 3, learning from certain nations like the Czech Republic which had made masks mandatory much earlier. Then, States such as Maharashtra and U.P. made masks compulsory, and the Ministry of Home Affairs did so as part of lockdown rules.

However, a concerted nationwide drive to ensure universal mask use has remained lacking. Did appropriate masking practices receive enough airtime and space in newspapers? Did we configure locally customised strategies to ensure widespread adherence and adequate provisioning? Did we strongly counter pervasive instances of improper mask-wearing, particularly those televised daily? It is possible to become complacent looking at the large numbers wearing masks in public places, and this could hide many dangers. Certainly, masks are yet to receive the kind of emphasis that physical distancing or mass quarantine have, in a country where the latter are a luxury. The explanation is simple: the population-level significance of masks has not been fully appreciated.

All the more crucial now

The continuing indifference despite today’s changed times is even more staggering. The lockdown has now been relaxed in most places. The peak looks far away. With community spread presumably rife in many parts of the country, measures like contact tracing and increased testing are increasingly becoming irrelevant. Preparing hospitals for a deluge of patients and holding down deaths is the new priority. Additionally, a stream of fresh evidence has emerged on widespread mask adherence helping to reduce community spread, resume economic activity, and tide over the crisis without needing a total lockdown. It is anybody’s guess that all these should have prompted renewed attention to widespread masking, but the same is elusive. Again, the imported mantra of ‘test, track, and trace’ continues to consume a disproportionate share of attention. With the highest government echelons still in denial of community transmission, this shouldn’t entirely come as a surprise.

A change in our approach towards masks is imperative. Only when its population-level significance is fully comprehended will comprehensive strengthening on policy, promotional, and regulatory fronts follow. The additional lesson, considering that this a long-drawn-out battle, is that dilution of local thinking cannot be afforded at any step.

Soham D. Bhaduri is a Mumbai-based physician, healthcare commentator, and editor of ‘The Indian Practitioner’

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Printable version | Jul 11, 2020 11:17:34 AM |

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