Friday, October 09, 2020

Confusion on Pandemic Protocols Demonstrates We Have Poor Leadership

 The social website "NextDoor.com" is a platform where neighbors can discuss local issues. I first learned about it when my sister-in-law used it in her neighborhood to call out for a request to borrow a wheelchair, and a neighbor of hers (who she did not know) offered to lend us a wheelchair for free. It seemed like a nice idea. You have to be a neighborhood resident to participate.

Sometimes, debates that break out on NextDoor are very revealing of cultural issues in American society. I find, for example, that some people are very scared by shootings, and find it necessary to reply to a story by commenting with a few words like "Scary!" or "That's awful." While it is true that shootings are horrible, I don't feel the urge to post such messages, and I also note that few of these shootings are robberies or random. I view them more as sad and worrisome signs of social disfunction than as personally scary.

Yesterday there were over one hundred posts in just a few hours responding to a mother who said her small children, 2 and 5, were being harassed two little boys and using foul language in the neighborhood park. She threatened to call the police and post pictures of the boys on NextDoor if the parents did not reply to her message. This led to an outpouring of comments, most saying that one should never post pictures of minors on social media without permission, and criticism of the threat to call the police, given the problem of police violence. The mother replied with a very measured message, thanking the poster for letting them know of the problem, and saying that foul language and bad behavior was definitely not tolerated in their home and she and her husband would be talking to the boys and going to the park with them in the next couple of days. But she also pushed back at the threats to call the police and post the boys' pictures. Her reply was great; many of the comments were embarrassing, so I did not read most of them.

A few days earlier, a Black WashU student who lives in an apartment with other Black female students wrote to complain that neighbors had called the police on them, once for her roommate screaming loudly in frustration over something, and another time because they were making too much noise playing music at 10:30 pm, celebrating a birthday. The police had been very disrespectful and actually made the birthday girl cry. The student, very reasonably, asked that neighbors come over and talk to them before they called the police, as they did not mean to bother anyone, and police encounters for Blacks are fraught with danger. This led to a vigorous back and forth, as some said they should have known that quiet time in University City starts at 10 pm, others saying it is not right to expect people to confront neighbors since people have guns and you don't know how they might react. One writer accused the student of being privileged for being able-bodied, because she would not have been able to go up the stairs to the women's apartment to speak to them. When you read some of these exchanges, you can't help but feel that social media makes conflict and polarization worse, not better.

Today a dispute is brewing on my NextDoor feed over Covid and masks. Here is the first post:

Laura Central West End West

Covid-19. I’ve been riding my bike or walking in Forest Park and I always wear my mask. If I don’t see anyone near me I occasionally pull it down but mostly just keep it on because many times people ride or run right next to me from behind without masks on. I’d say 95% of people at the park do NOT wear masks. And they don’t stay 6’ away either. What’s up with that? Missouri’s numbers are high and this is probably the reason. It’s so frustrating. Please please think of others. At least wear it on your neck and pull it up when you walk, run, or ride next to someone.

Of course, this leads to replies like this:

Central West End West
I don’t wear a mask outdoors. I try to stay well separated, but I don’t believe that passing by someone is dangerous. Indoors is very different.
 
Central West End West
Just wear the mask, please. Indoors or out.

B.B.  • Central West End West

Dosage makes the poison. COVID tends to transmit in longer (15 minutes or more) close interactions in areas with poor ventilation. There is almost no chance of transmitting COVID in an incidental pass while running or biking. Masks certainly reduce the chances of transmission, but the chances of transmission outdoors are near zero.
• 
Academy
You're pretty dumb to be wearing a mask out doors. I haven't been wearing a mask for months. There's no Law Karen! I'll never wear a mask unless it's super crowded and we have to.
 • 
West End 
Not dumb, just socially responsible, considerate, and intelligent. If others were the same, the infection and death rates from Covid-19 would be much lower. To be in denial about this isn't smart, it's irresponsible.
Amber • Academy
You go outside to get fresh air. Not wear a mask. Most people wont wear one outside so you assume that risk. The chances of it being transmitted passing by in 3 second timeframe isnt likely. Mask should be worn indoors wheres there an inclosed space. Just dont sneeze on anyone and its not a problem.

• 
Central West End West

I don’t believe the evidence points to there being much risk with a quick pass without a mask while walking/running/biking. I don’t think I’d be able to wear a mask while running or biking in Forest Park. 
I also think it’s important to give people space outdoors. I’m often frustrated when groups of 2 or 3 take up a lot of the path when I’m running outdoors without a mask, and I can’t get 6 or even 3 feet away.
 
 • 
Central West End East

There is essential no danger of infection from briefly going by someone outside, several feet away (excepting, say, someone coughing or sneezing in just that  correct instant with the breeze in just the right direction). Walking on a busy sidewalk is a different matter, as then you are passing many people fairly close together, and passing time is much longer. But jogging or biking in the park, you are almost certainly not near anyone for more than a half second.

 • 
Central West End East

So ridiculous! There is fresh air all around you and you are poisoning your lungs with breathing your own breathe, just stupid! Keep riding that bike and being a Karen, sooner or later you will be too sick to ride it, so stupid!


• 
Skinker DeBaliviere

I agree with you, Laura. I wear my mask when I take walks at the park and then distance myself when someone is walking toward me. It is the responsible and safe thing to do.

And on it goes. Social media provides an interesting insight into our culture. And it ain't pretty.

For the record, I do not believe it is necessary to wear a mask in the park. If the issue were not so politicized, and if we were not also arguing over whether it's necessary to wear masks in stores, for example, then we'd have a consensus based on available science. But clearly while we have lots of opinions, there is no agreement on what we should do. The CDC's advice is not entirely clear, though it seems to take the precautionary principle; it says in guidance on visiting parks:

Wear a mask as feasible. Masks are most essential in times when social distancing is difficult, including when hiking on trails that may be popular or crowded.

 It's easy to urge everyone to wear a mask "as feasible," but the advice gets ignored if it does not seem to square with other advice we're given, such as the notion that people need to have close contact for 15 minutes or more to be at risk. If our Dear Leader were not intent on trying to "avoid panic" and denying the seriousness of the pandemic, then maybe such divisions would not be so sharp.

Monday, May 18, 2020

St Louis Relaxes Restrictions: Sociocultural Patterns of the Covid-19 Pandemic


Tomorrow the Covid-19 restrictions in St Louis City and County will be relaxed. The state of Missouri was one of five states that “opened for business” on May 4, which nearly all health professionals said was too early. The City and County now open, two weeks later, but also before the numbers justify it, before testing and contact tracing are in place, so that we risk having another flairs-up. But there are many uncertainties: will people really be willing to go to restaurants? How much difference will wearing masks make? Will most people actually be willing to wear a mask in public?


I spoke with a former secretary in Hong Kong by phone on May 1st, and she was horrified at the Covid-19 situation in the US, and worried for my safety. I realized in talking with her that the news media portrayed a picture that makes the situation seem perhaps worse than it is, though since Hong Kong has only had 1,053 cases and 4 deaths, in a population of about 7.4 million, the situation in St Louis City and County is indeed much worse: with a population of only 1.32 million, we have 5,918 cases and 431 deaths. More importantly, my county reported 51 new cases today, and 4 more deaths. Many worry the pandemic will just pick up again.

Americans live much more spread out than do people in Hong Kong; single family homes are the rule. Americans can easily shop at supermarkets and only go out once every 8-10 days to buy all their groceries (I go to one store, with a shopping list, wearing a mask, and can be in and out in about 30 minutes). I go to a nearby park to exercise, either running (OK, mostly walking) or on bike. The chances of me getting sick are as close to zero as possible.

In Hong Kong, I lived in an apartment building, on the 7th floor. Most people have to take a bus or train to get anywhere. Elevators, public transit, and crowds on the street, all these add to the risk. This is part of the reason why Hong Kong is working so hard to completely eliminate the virus from the city.

Eliminating the virus was probably never possible in the US. It came from many different directions (via Wuhan, via Italy, via Paris) and was spreading locally before authorities were even aware of its existence. Hong Kong could close its borders, particularly the border with China, but there is no border between states in the US. Trump floated the idea of quarantining the New York City metropolitan area, but it was impossible to do, so he dropped it. The US also has never had the public health infrastructure (e.g. contact tracers, local government personnel) in numbers sufficient to do contact tracing in an epidemic.

Of course, add to that the string of failures of the US government: failure to have PPE stockpiled, failure to plan for an event that would affect the entire country at once, and the failures with the tests. A friend who is a nurse tells me her hospital is still recycling N95 masks, even though they were designed to be single use disposable. The story of the failure of the US response is very clear and was documented early on (see Atlantic story from back on March 21 here, Vanity Fair here, and WaPo here, for example.)

In addition to the different geography of the cities and areas, there is the history of epidemics. Having experienced SARS (and MERS, for Korea), East Asians were not only better prepared but also on the lookout for the next epidemic. Here LINK is a fascinating article about the Taiwanese doctor who went to Wuhan in mid-January, when the outbreak was still not well understood. But he was cautious and informed enough to decline his Chinese hosts’ invitation to dinner in a restaurant. Smart move. And of course, Taiwan’s vice president is an epidemiologist, so they had a real scientist in charge.

In the US, the speed of officials’ responses depended on many factors, including their historical experience with epidemics, but also how much the officials were willing to listen to scientists. Charles Duhigg has written an interesting article contrasting the different ways officials communicated the danger in Seattle and New York. Though the outbreaks emerged at about the same time, the Republicans and Democrats in Seattle were able to agree on a common message and “let the scientists take the lead,” resulting in a much more controlled outbreak in Seattle. San Francisco’s mayor Breed was initially criticizes for overreacting, but hassince won praise for her quick action.

It is amazing to me how uninformed most Americans are about testing and contact tracing, the two features necessary to contain the virus. The Q&A on NPR’s Corona Virus Update for May 2nd shocked me when a nurse who had gotten sick asked how they could trace who gave her the virus. The journalist had to explain that contact tracing was not tracing who she got it from, but who she might have exposed before she was symptomatic. If a nurse does not know that (and the radio host also sounded surprised), then clearly this is not a well understood idea. People also do not understand error rates and the limits of testing. It is more than a little depressing that a comedian like John  Oliver has a better grasp of the issue (and the importance of testing) than most politicians. Many are worried that states are relaxing social distancing before testing and contact tracing are up to a level that can suppress any new outbreaks. 

Hong Kong is being extremely cautious; only residents are allowed to enter the territory, and they have to be tested upon arrival and do a 14 day home quarantine (checked with a digital wrist band; see video here and Twitter feed here); though restaurants never completely closed, schools have been closed and administrative staff at my old university were taking turns staffing the office, one person at a time, until May 4th, when offices were back at full strength. Even the Cheung Chau Bun Festival (ironically, a celebration of the end of a late 19th century epidemic) was restricted and ultimately cancelled for the first time in 100 years, for fear that crowds might spread the virus, even though Hong Kong had reported no new cases for 10 of the previous 16 days and nearly all the new cases were from travelers coming home to Hong Kong. Of course, it is also true that the Bun Festival procession has been an occasion to mock government leaders, so it is possible the authorities were “especially cautious” to avoid being insulted. But in general, people seem to accept that the government policies are medically necessary. (As an aside, I heard an amusing incident in a recent Planet Money podcast where the journalist asked a restaurant manager in Beijing if most people supported the government’s restrictions on restaurants and she laughed and said “next question.” It is really pointless to ask such questions in the Mainland.)

So Hong Kong is relaxing restrictions, allowing people to gather in groups of eight instead of four, and allowing gyms and movie theatres to reopen on May 8. Schools will restart in late May.

But St Louis, and much of America, is opening up only because the peak has been avoided. In no way has the epidemic been controlled, and Michael Osterholm of CIDRAP says not one of the 42 states that have relaxed their restrictions have met the conditions originally set by the White House for Phase 1 reopening. All are responding to political pressure.

The economic problems caused by the epidemic are very real and severe. But many of the workers who are being asked to go back to work are worried that they might get sick, and that they could infect their family. A group called HealthB4Wealth is actually protesting the opening, calling it premature. And the head of the STLMetropolitan Covid-19 task force admits that political pressure led to settingan earlier date. (Note that the previous link is to the St Louis American, a newspaper serving the African American community. It is not a coincidence that the group got more and earlier coverage there.)

It dramatically obvious that poor people are suffering much more tragic outcomes from this pandemic. Blacks and Latinx get the virus, and die from it, in higher numbers (see here). And medical anthropologists would not be surprised. In fact, the journalists who broke the story of the disparate racial impact of Covid-19 for Chicago’s WBEZ have been researching how class and race affect health, so they were thefirst to realize that though Blacks make up 29% of Chicago’s population, theyrepresented 70% of deaths by early April. Days later, it emerged that the first twelvepeople to die in St Louis City were all Black. Since then, the press has stopped reporting the race of the dead, but several reports have said that most are African Americans.

Of course, there is nothing genetic about this. Blacks and Hispanics are more vulnerable because many are poor, so have had less medical care, and often eat high calorie diets because they are cheaper, so they end up with hypertension and diabetes, which make the outcome of Covid-19 infection much worse.

In addition, many of the so-called “essential workers” who could not work at home are minorities, so they have been more exposed, and therefore more likely to get sick. I was on a call recently when someone suggested African Americans were less likely to “social distance” or follow the rules; I think this is absurd. I heard of a wealthy family in the suburb of Chesterfield (83% white, 11% Asian, 4% Black) that tried to hold a party for a graduate last week. The 30 cars on the street gave them away, and the police came and told everyone to leave. I would be willing to bet that the rich are more likely to believe the rules don't apply to them, or that they are safer than the rest (which, in some ways, they are--that is privilege).

Because “essential workers” still have to go to work, often by taking a bus or train to get there, they continue to get exposed, and to spread the virus to family members. It is not a coincidence that 33 MetroTransit workers have tested positive for the coronavirus, and two have died. Wealthier and non-minority people can work and hide in their homes and remain safe. A recent article in the Boston Review examines the shameful history of racism in St Louis, and the role it plays in the Covid-19 epidemic. 

What is frustrating, to me, is to see people who push for the economy to “reopen” without realizing that they are relatively privileged and protected, but a) still vulnerable, and b) can infect others. The Atlantic recently had an article that argued “Georgia’s brash reopening puts much of the state’s working class in an impossible bind: risk death at work, or risk ruining yourself financially at home. In the grips of a pandemic, the approach is a morbid experiment in just how far states can push their people.”  Non-Americans often do not realize that “essential US workers often lack sickleave and health care – benefits taken for granted in most other countries.”  That results in people going to work even when sick, because they or their family need the money, or because they fear being fired if they miss work. That is not a way to fight a pandemic.

Some who are frustrated by the government restrictions even go so far as to claim the whole coronavirus is a hoax. One such person wrote a screed on my NextDoor feed today, claiming that no one is actually dying of it. I’d like to think she was drunk, but I fear she was just watching too much Fox News. When the epidemic began, it was emphasized that “we’re all in this together.” But now, the racial fault lines, and political fault lines, are growing wider. Journalists already commented in early March on the early partisan division, but now it has become particularly toxic (NY Times 1 March and The Atlantic 20 March). 

Some people even refuse to wear masks, viewing the imposition of masks a threat to their freedom. One NextDoor post replied to a polite message that mentioned wearing a mask this way: “Your demand that someone else wear a mask to allay your fears is a pernicious form of bullying, so please knock it off.” Fortunately, the original poster replied politely again:
I wasn’t demanding that anyone wear a mask, simply asking for people to wear masks as a courtesy to others, and to help stop the spread of the virus. No reason to be afraid of the virus, just be cautious and aware of it. However, your response seems a little on edge. Maybe I’m just reading it wrong, tone isn’t always well conveyed over the internet. But if you are feeling on edge, let me know if you need someone to talk to. I would be happy to help

This is a good example the American individualist, who thinks that he/she should be able to do whatever they please, and don’t understand how their actions can impact other people. If it was not so self-centered and childish, it might be funny, but in a pandemic, it’s alarming. Here’s another example just in from NextDoor:
...And all I want to do is go to the pool.  I have read two articles stating it is safe to swim in the ocean and indoor pools.  None saying it is not safe.

Open up the country.  If business owners don’t want to open yet, then don’t open.  If people don’t want to go out yet, then don’t go.  If employees are afraid to go back to work, there are 36 million waiting for a job.  We are adults.  We have seen what this virus can do.  We have been told 20 times a day how to keep ourselves safe.  We are adults, let us make the decision about where we go when. 

I sympathize with her frustration, also because the rules are different in different states; Pennsylvania did not allow gardeners and outdoor construction, while most states did. Still, the naivete of this author stunning. It is true that articles say pools are safe, but all the articles also say that the dressing rooms, toilets, and poolside are all places where contagion would be likely. And if she gets infected, it is not just her that is affected: she will go to stores and the supermarket, and could infect others, especially the pool staff and other “essential workers” who cannot protect themselves as well as she may be able to. So it is not just a matter of everyone deciding for themselves what risks they are able to accept. American notions of freedom and liberty seem to prevent some people from understanding how they are tied to others in webs of relations.

The expensive consultants McKinsey just sent me a report which says:
Uncertainty about the continuing spread of the coronavirus makes people fear for their health and their lives. Uncertainty about their livelihoods makes them cautious about spending. Under high uncertainty, business leaders find it impossible to make reliable plans for investment.
This uncertainty is toxic for our economic recovery.
The objective now must be to crush uncertainty as soon as possible.
Good luck with that. Uncertainty will be with us for a long time. And states can “open” their economies, but will customers go back to restaurants and movie theatres? How much of a difference will masks and handwashing make, especially if some people actively refuse to comply? There is plenty of uncertainty, and it is likely to last quite a while.

Monday, April 27, 2020

Covid-19 Uncertainty: Be willing to say “We don’t know”


Like many people, I find myself distracted by the virus, as if infected by a different virus that makes me into a zombie that has to read the news. I find myself unable to stop reading about models and what the exit strategy will be for the “stay at home” orders in the US and elsewhere. Policies in Sweden, Taiwan, Korea, and elsewhere are all fascinating. I know many others are infected, too; friends tell me, and journalists write about it.

At the root of the problem is uncertainty, which is something I’m thinking a lot about in my research on pesticides, too. Though we now know a lot more about the Covid-19 virus (and doctors are better able to treat patients), there are many things we still don’t know. Most importantly, we don’t know what the world will look like after the pandemic passes, and when that will be.

Some people are able to just live with the knowledge that we don’t know. A friend wrote to a small group of us proposing a trip sometime next fall, and when I wrote back “I think it is going to be more than a year before we can travel freely, don't you?,” another friend wrote curtly, “Guessing game at this point.” Since he is a surgeon, I was about to write back, “Well, you must have some model in mind.” But then I realized he was right; it is pointless to speculate, and I just have to accept the uncertainty.

And there is a lot of uncertainty. While China, Taiwan and Korea have done a great job containing the virus, how long can they maintain their containment policies, including closed borders? Paradoxically, the chaos in the US and much of Europe, including the lack of preparation, slow reaction and lack of testing, may lead the US to develop a herd immunity that allows the US to come out of the epidemic earlier than areas that contained it better.

We don’t know whether a vaccine is possible; after all, we don’t have a vaccine for other coronaviruses. So it is possible that the only exit strategy for the virus is to keep the epidemic at a low level, so that it does not overwhelm the hospitals, until the population develops enough immunity that the virus does not spread very easily. This, essentially, is the Swedish path, where people are encouraged to keep social distance but there has been no stay at home order.

As doctors learn how to treat patients better, the death rate is declining, and may soon be lower than the death rate for the annual flu. But at this point, we don’t know, because we don’t really know how many asymptomatic cases there are, so we do not know the total number of cases, which is the denominator for the death rate (death rate = # dead/# infected). So while we currently think the US is a mess, and that Southern governors opening up their economy now seem irresponsible, the US and Sweden may turn out to be the better way to get out of this pandemic. We don't really know.

Some people are obsessed with knowing whether they have had the virus. A friend of mine told me of a group of co-workers who decided to get antibody tests (which are starting to be available here for $200-$260 (see one example here). The test checks your blood for antibodies to tell you whether you have had a Covid-19 infection and developed the antibodies. I asked why they wanted this test; they said they “just want to know.”

This is very odd, because though they think they will be liberated after a positive test (meaning they have antibodies for Covid-19), actually, their behavior should not change whether it is positive or negative. If they are negative, they still have to wear a mask and stay home. If they are positive, they assume that if they have Covid-19 antibodies, that they cannot be re-infected. They are probably right, but we don’t know this for sure. One study found low levels of antibodies in recovered patients, suggesting they may have only weak or no immunity. There have been a few anecdotal cases of apparent “re-infection,” and while it is more likely that their original infection just lingered (i.e. that when they were supposedly recovered and virus free, that they still had the infection), we can’t be sure. So to be cautious, they should still practice social distancing. Furthermore, it is not like they can suddenly go to the movies or to restaurants: they are all still closed, and few of their friends can go anyway.

In addition, there are serious doubts about the reliability of these serological tests. There are now only four tests approved by the US Food and Drug Administration (FDA), but 107 that are merely self-validated andpossibly fraudulent or unreliable. Those are the tests that are easily available, of course.

Even with a “reliable” test there is a problem, because most tests are only 95% reliable, meaning that they make a mistake 5% of the time. If I test positive, it is more likely that it is a false positive. In Missouri, it is very unlikely that any one person has had a case of Covid-19. When rates of infection for California came back at between 1.5 and 2.4 percent, experts thought these figures were much too high. Though a recent study suggests NewYork City may already have a 14 percent infection rate, experts are skeptical. Certainly, in the St Louis metropolitan area, where we have 2,720 cases as of yesterday, (0.1% of our area population, and 127 deaths), the chances of anyone being infected is very small.

The main problem with testing, however, is that it is interesting and important for epidemiological understanding of the epidemic, but is not very useful for the individual. Specifically, if a population’s infection rate is low, say 2%, then a test that is 95% accurate is not very helpful. If I test positive, I have roughly the same chance of being truly positive and of being a false-positive. Ninety-five percent accurate sounds good, but it is not if you are testing for something that is very rare. (To think with another example, since Yellow Fever is extremely rare in the US and few have antibodies for it, if I take a test that turns out positive for Yellow Fever antibodies, it is a lot more likely that the test is wrong than that I had or was exposed to Yellow Fever.)

Testing is key for public health purposes. We need tests to see who has the Covid-19 disease so we can be sure to isolate them and then contact all who have been in contact with them, so they can self-isolate. And for public health purposes, everyone should wear a mask to avoid infecting others in case they have the virus, and they have to wash their hands regularly and avoid crowds.

But if you are sick, it does not matter whether what you have is the flu or Covid-19; the treatment is the same. You are going to have to let your body’s immune system fight the infection, just like you do for any cold or flu. You need to protect others as though you are infected with Covid-19 (or any communicable disease): isolate yourself, avoid contact with others, wash your hands and keep your dishes and cups separate, etc. From my individual point of view, if I have a fever and shortness of breath, I have to just assume that I have the coronavirus. But people want to know, so they want to take the test.

Models are the most sophisticated ways we try to predict how the pandemic will unfold, and they help us think clearly. There are even peoplewho take a “wisdom of crowds” approach and use multiple models to estimate more accurately (sort of what 538.com does for political polls). One expert claims that as the pandemic has progressed, predictions have become more accurate, but that is a bit like saying that as you drive closer to your destination, your prediction of your arrival time is more accurate. By the time the pandemic is ending, we will not have much uncertainty. In the meantime, I'm willing to say, "I don't know."



Wednesday, April 01, 2020

The Science and Culture of (Medical) Masks


There have been reports the CDC is reconsidering its recommendation that people not wear a surgical mask when they go out (see WaPo story here and NY Times story here, for example). As it has become clear that asymptomatic people can transmit the coronavirus, more and more Americans have been wondering whether it would not be a good idea for ordinary people to wear masks all the time.

Scientists have long said that wearing surgical masks to protect against SARS and Covid-19 is not effective. The scientific view is that surgical masks help prevent someone who is infected from spreading the virus, but wearing a mask does not protect against becoming infected. (Here is an adamant position against non-sick people wearing masks, from 29 Feb.)  As this NPR story from 2015 notes, masks are good if you are sick so you don’t spread germs to others, but it is better to just stay home. The CDC, as of today, only recommends wearing a facemask around other people if you are sick, or if you are in the same room as someone with coronavirus who cannot wear the mask (e.g. because of difficulty breathing). 

The Hong Kong health authorities during SARS essentially agreed with this viewpoint, and said that people should wear masks to avoid stigmatizing anyone who had to wear a mask. The thinking was that if only sick people wear masks, then they would be discriminated against; people who should wear one would not do so to avoid being shunned.

Actually, most Hong Kong residents felt that wearing a mask would help at least a little, and even if they had doubts, “it’s better to be on the safe side” and “it can’t hurt.” It has gradually become common sense that wearing a mask protects the wearer. And this approach predominates with the coronavirus; the Hong Kong government encourages people to wear a mask when they go out. This is contrary to the WHO, which only recommends wearing a mask if caring for an infected person.

An opinion piece in the NY Times by the medical anthropologist Christos Lynteris argues that though there is little evidence that wearing a surgical mask is a good prophylactic against the coronavirus, in Asia wearing a mask is a sign of being modern, of taking hygiene seriously, and of concern for others because wearing it prevents the spread of the virus if the wearer is asymptomatic. Chinese first wore masks in 1910, when the Cambridge-educated doctor Wu Liande recommended the use of gauze masks to fight the pneumonic plague. He was right, and his success, in contrast to European doctors at the time who disagreed with him, was a source of pride for Chinese and began the custom of wearing masks against contagion, Lynteris argues.

But it was SARS in 2003 that made mask-wearing ubiquitous in recent times. I was in Hong Kong at the time, and no one went out without a mask. However, it has never been shown that the wearing of masks was significant in winning the battle against SARS.

The PRC government position is that before hospital personnel realized there was a coronavirus outbreak, many hospital workers contracted the disease and dozens died. The government then mobilized 20,000 doctors and nurses from the rest of the country to go to Wuhan to deal with the epidemic, and all used masks, eye shields and gowns, and none of them were infected. George Gao, a leading Chinese researcher, says it is a mistake that people in the West are not wearing masks, because asymptomatic and pre-symptomatic cases can spread the virus.

There are three issues with having everyone wear masks. First, the medical effectiveness of ordinary people using masks and N-95 respirators is not clear. This MedpageToday article from 2009 shows how contradictory the evidence has been, with many tests showing no benefit to wearing a surgical mask to avoid contagion.  A recent Lancet article includes a box that shows most countries agree there is no benefit to the public from wearing masks.

But then you have non-medical commentators, like this AI entrepreneur, who think the argument for wearing masks is clear, and who calls for everyone to wear masks. (It's funny how people successful in one field, especially rich people, show no hesitation about propounding on other areas outside their area of expertise.) The problem with masks is that if they are not worn, removed and disposed of correctly, they are of little use. The “best” masks, the N-95 respirator, makes it very difficult to breath if it is worn properly, with edges sealed. (And one cannot have facial hair and seal the edges.) Some have said (and I know from experience) that even walking is difficult when wearing the N-95, if it is worn properly.

The second issue is the shortage of masks in the US. When Covid-19 struck, the government stockpile of N-95 and surgical masks was way down because of a failure to restock after the 2009 Avian Flu epidemic (blame for this can be spread widely). The CDC and other authorities’ recommendation was that the general public NOT wear masks, and that they leave them for the health professionals who really needed them. There are horrifying reports of many hospitals and nursing homes where staff have to reuse masks. By comparison, during SARS, we were told in Hong Kong that we should replace the mask once it became wet from our breath, roughly every two hours. So one can’t help wonder whether the calls for the public not to wear masks are because of a kind of rationing, giving priority to those who benefit the most, rather than that the masks do not help at all. But of course the argument that they do not help long precedes the coronavirus crisis.

Third, there is the issue of the image of masks. Americans have been giggling about Asians wearing masks for years, and I’ve noticed that in a number of cases of reported anti-Asian incidents, the victim was wearing a mask (on 'maskphobia' see here). A number of Chinese friends have been shocked at Americans’ reluctance to wear masks. This humorous video sums up American’s views on the wearing of masks. 
The lyrics say:
Don’t wear masks
They don’t work
(and plus you look like a jerk)
You might think you’ll help a billion
but you scare the little children!
While in Asia, wearing a mask is seen as pro-social, protecting others from one’s own possible infection, in the US it is a sign of being sick. Americans have a strong antipathy towards medical masks, which is surprising because everyone wore a mask during the 1918 pandemic (see here and here). This crisis may well change American attitudes.

The anthropologist Gideon Lasco has noted
People’s motivation for wearing these masks goes far beyond simple considerations of medical efficacy. Cultural values, perceptions of control, social pressure, civic duty, family concerns, self-expression, beliefs about public institutions, and even politics are all wrapped up in the “symbolic efficacy” of face masks.
Which leads me to wonder if libertarian and other Americans skeptical of the government will not resist and even refuse to wear a mask. The same people who think Covid-19 is "political" will see wearing a mask as some sort of government plot. Already skeptical of science, they will wonder why the establishment has changed its mind on masks.

Interestingly, US hospitals have rules against medical personnel wearing masks that seem to focus primarily on not scaring other patients and avoiding the impression the hospital is germ-filled. Several doctors who insisted on wearing a mask in hospital hallways have been disciplined and fired, though it seems some hospitals have reversed themselves. As this NYTimes article today puts it: 
Amid the confusion, furious and terrified, doctors and nurses say they must trust their own judgment. Administrators counter that doctors and nurses, motivated by fear, are writing their own rules.
As the article notes, some hospitals are insisting that masks are not necessary, and are insisting on all staff sticking to the rules. Other hospitals are allowing, or even recommending, that caregivers wear surgical masks at all times at work.

This article from WebMD yesterday (30 March) says that wearing even a homemade mask might help, but hand washing and keeping distance from others are more important. Many reading that article will think, “Better safe than sorry,” and decide to wear a mask.

Since we will not eliminate the virus but can only try to control it, i.e. prevent its rapid spread, I can’t help but wonder, after the “stay at home” rules end on April 30, will the mask will become required when in public? We face many months of continuing, albeit hopefully low level infection, until a vaccine is developed or sufficient immunity in the population allows the epidemic to burn out. Already an article from 20 March in The Lancet argues for widespread use of masks, calling it a “rational recommendation”:
“As evidence suggests COVID-19 could be transmitted before symptom onset, community transmission might be reduced if everyone, including people who have been infected but are asymptomatic and contagious, wear face masks.”
Interestingly, of the six co-authors, two are based in Hong Kong (the rest in the UK) and five have Chinese names (the one Anglo name is based in Hong Kong). One wonders how much Asian attitudes towards masks influenced their recommendation. Conversely, one wonders what cultural attitudes make Western medical researchers resistant to the generalized wearing of masks. This really shows how cultural attitudes can influence scientists' judgement.

It seems we are close to a tipping point where everyone in the US will be allowed, or even encouraged, to wear a mask. But it will be hard to know if it is medically advantageous and appropriate, or is being done primarily to make people feel protected and more in control. But first the country needs a supply of masks.