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.

Covid-19: toilet paper and containment

Two Covid-19 issues have been weighing on my mind: toilet paper hoarding, and virus containment.

Many have been asking why people around the world have been hoarding toilet paper. A friend of mine captured the irrationality of people hoarding toilet paper by saying “It’s because they’re scared shitless!” 

There is a long history of toilet paper shortages during crises; the US had a run on toilet paper in 1973, in part created by a joke told by late night TV host Johnny Carson, but coinciding with shortages of many other consumer items, including gasoline (petrol).

I’m especially intrigued by this run on toilet paper because it seems to have started in Hong Kong, and spread to much of the rest of the world. Hong Kong even had a widely reported case of a toilet paper robbery. There seems to be something cross-cultural about the phenomenon.

Few of the articles on this phenomenon really offer a good explanation (see SCMP Agence France-Presse article). CNN.com offered a list of explanations on March 9th that included:

1. Reason 1: People resort to extremes when they hear conflicting messages
2. Reason 2: Some are reacting to the lack of a clear direction from officials [Hmm, this sounds like Reason 1]
3. Reason 3: Panic buying begets panic buying [This is true; now that there is a shortage, I have no choice but to try to buy toilet paper. This is the “game theory” explanation. But it does not explain why the panic buying started in the first place.]
4. Reason 4: It's natural to want to overprepare. [Really? Why focus on toilet paper and not tuna or beans?]
5. Reason 5: It allows some to feel a sense of control [Control what?! An uncontrolled bowel?!]

So the psychologists say that by preparing when they feel helpless, even just by purchasing toilet paper, people get a sense of control. But none of these reasons explain why “toilet paper” and not, say breakfast cereal. After all, diarrhea is not one of the symptoms of the coronavirus.

This is actually a classic cultural, and thus anthropological, question: why do people value one thing over another. Economists can tell you where supply meets demand, but they assume demand exists. Anthropologists want to know what creates demand for a particular thing, i.e. why it has value.

Here is a better explanation. Niki Edwards, School of Public Health and Social Work, Queensland University of Technology:

Toilet paper symbolises control. We use it to “tidy up” and “clean up”. It deals with a bodily function that is somewhat taboo.

When people hear about the coronavirus, they are afraid of losing control. And toilet paper feels like a way to maintain control over hygiene and cleanliness.

So, to really get at the root of the phenomenon, we need to look at the symbolism of toilet paper. The “control” some people talk about is not controlling the disease, but the control of bodily functions that we usually rather not think about. People think of toilet paper as essential for “hygiene.” People are also told to wash their hands after they go to the bathroom. Thus, toilet paper is associated with hygiene and hand washing.

Indeed, a lot of the “hygiene” people follow to protect themselves against infection is not really effective. During SARS, there were many reports of people cleaning all the door knobs inside the house, even though they were in isolation at home. With no outsiders coming in, it is hardly necessary to wipe door knobs. The same is happening now in the US. I've heard of people washing their hands compulsively even though they are in isolation. And in one business I know of, though there are less than 10 managers left working in a large office, they have cleaning staff come through the office numerous times a day to wipe down and disinfect surfaces. I think the managers would be safer if the cleaning staff did not come, but the idea that surfaces should be “disinfected” and “cleaned” is very powerful.

  

Containment vs Mitigation

When Americans look at what China did to control the Covid-19 virus, they tend to attribute it to China’s authoritarianism. It is true that there are aspects of China’s response which were possible only because of the authoritarian state—including the denial of the problem for 3 weeks, when doctors knew the virus was serious and spreading (though we still, even today, March 28, have officials in the US downplaying the seriousness of the epidemic). But most of China’s response is not due to the authoritarian nature of the state, but to state capacity. China was able to trace contacts and impose quarantines because it had the health care personnel to do it. Proof that it is not due to authoritarianism is the fact that Korea and Taiwan were also able to react as quickly, but are very robust democracies. In Korea and Taiwan, people who came down with Covid-19 had their contacts traced and notified, and some were put in isolation to prevent them from further spreading the virus. This has helped contain the virus in China, Korea and Taiwan. (For an article on Korea, see here; on Taiwan, see here.) 

The US did not do that. Authorities delayed responding. Already in mid-February, experts were saying that the opportunity to contain the virus in the US was close to finished. (See for example Tom Bollyky of the Council on Foreign Relations, “Expert: It’s close to the point where governments decide thecoronavirus outbreak is a mitigation vs. containment situation”)

In one case, in Westport, CT, on March 5, 50 people at a party were exposed to the virus and dozens subsequently came down sick.   “Even in a well-connected, affluent town like Westport, contact tracing quickly overwhelmed health officials. ... One of the party guests later acknowledged attending an event with 420 other people, he said. The officials gave up.” This is because they lack the capacity, and perhaps the will. The parts of Asia that went through SARS were more aware that contact tracing was important. 

Contrast this with what was done in China. First, everyone who traveled to other parts of China from Wuhan was forced by local authorities to quarantine. Note that this sounds oppressive and authoritarian, but they were able to do something similar in Taiwan and Korea. Then, they closed off neighborhoods with infections, forced visitors to go through 14 days of quarantine before going to work, and placed restrictions on restaurants (but they did stay open, in contrast to ours which are all closed). I highly recommend this 12 minute video (in window below) by a Japanese businessman based in Nanjing, which was not heavily affected by Covid-19, but you can see the efforts the city went through to contain the epidemic. 

Containment may also be difficult because Americans are more mobile (though I don't know if this is true); this video by Tectonix GEO shows how the cell phones of spring break partiers (known as Covidiots) on a beach in Fort Lauderdale spread to the rest of the country in the following weeks. This video shows how people from the New York metropolitan area spread over the entire US in the two days after Gov. Cuomo announced #stayhome rules. But millions of people left Wuhan for the Chinese New Year before January 25th, and yet China’s local authorities were able to prevent them from transmitting the virus locally by requiring visitors to isolate at home. Taiwan was also able to contact tens of thousands of residents who arrived from China to contain the spread of the epidemic. But the US does not have neighborhood associations and health authorities like Asian countries have.

It is not because China is authoritarian that containment was possible; it was because they had state capacity. The same is true for Taiwan and Korea. In part, the experience of SARS in Asia meant that states there prepared better. But the US is also underprepared because Americans, and especially libertarians and Republicans, distrust state power. Trump dismantled the pandemic response team in 2018 that had been created by the Obama administration. 

A weak state is not a bug; it is a feature of America. The Trump administration has been cutting budgets of all government departments, including the CDC. The “small government” ethos is strong in America. It is linked to ideas of freedom and liberty. You can see this skepticism of the government and of public health officials, that grows from a fear of state power, in websites like this of the libertarian magazine Reason.

No one knows what will happen with this pandemic; as thisblog post says, every model and prediction we read “is just a guess but with statistics.” (But he’s not simply dismissive; he adds, “All models are wrong. Some models are useful.”). And it is useful to go back to the Feb. 13 NY Times article interviewing Donald G. McNeil Jr., their health and science reporter who has covered epidemics since 2002, to realize how little was known as late as mid February. There are still important questions about the mortality rate, like why the rate is so much lower in Germany than Italy.   

But the chance for the US to contain the virus has passed. China, Korea, Taiwan, Hong Kong and Singapore have largely succeeded but are still fighting to contain the epidemic. In the US, because of a lack of testing and the debacle over tests, and because we don’t know how reliable the tests are anyway, we have no idea what percentage of the population has been infected. But now the US has passed China and has the most confirmed cases in the world. Rah rah patriots can cheer, “We’re number one!”

As long as people worry that going out will expose them to coronavirus infection, the economy will not rebound, even if authorities do relax restrictions. President Trump and a number of business leaders want people to get back to work, but the epidemic has to recede before people will go to the theatre, to the mall, and to restaurants, not to mention travel internationally and take a cruise. The chance to contain the epidemic has passed. Mitigation will be long and messy, and it is hard to know how and when it will end.

Still no need to panic, but need to be cautious

Re-reading my previous blog post, I feel that my emphasis was wrong. While there are no incorrect facts, the takeaway message now seems wrong. I did not sufficiently emphasize that the peak of infections can easily overwhelm hospitals. Currently, a doctor friend told me St Louis University hospital has only 10 vacant beds out of 65 ICU beds. There are only1888 ICU beds in the entire state of Missouri (population about 6.1 million). The number is low because of cost-cutting, especially since 2008, because having empty beds is “wasteful.” But reducing the number of beds so they are mostly being used reduces our capacity to deal with crises. As a doctor friend put it, “Hospitals in the US are already always running at 110 percent.” The additional serious cases of COVID-19, even if they are only 1 of 100 who get sick, can still easily be too many for the hospital to cope, and doctors will have to decide who gets the ventilator and who dies.

Three articles this past week, a piece in Medium by TomasPueyo, an article on Vox, and an article in the NY Times byNicholas Kristof and Stuart Thompson, make the point that the problem is not treating the disease itself, but is going to be treating the sick at the peak of the epidemic when hospitals are overwhelmed. I highly recommend these articles. The Times article also has a table that shows that the peak of the epidemic is likely to be in July, which means Americans' current “social distancing” is going to have massive economic effects.

It seems everyone I speak to has seen the Tomas Pueyo article, and I see now that it has been viewed 35 million times in 6 days. It gives me hope that ideas can, in fact, sometimes change people's ideas and behavior!

In the US, everything changed this week. Universities started closing on Tuesday, March 10, and the NBA suspended the season the next day. That was when everyone knew it was really serious. I don’t know all the factors that have gone into closing universities, but I’m told a major issue is uncertainty over a university's liability if they stayed open and someone got sick and died. It is easier to close. This is disturbing, because it is not clear what foreign students are supposed to do, and the extra travel this causes is precisely what we don’t want if we’re trying to prevent the spread of disease. I would have thought isolating the campus from outside visitors would have been more effective, in public health terms. But, I’m not aware of all the considerations. And I’m grateful I did not have to make these difficult decisions.

One thing I did not anticipate in my earlier blog was that Americans would take no precautions at all. I did not realize how unscathed the US was from SARS. Many friends who lived through SARS in Asia have commented on how blithely Americans have been taking the epidemic. I have not been panicking, but I have certainly been washing my hands a lot and avoiding crowds. I open doors with my back (to avoid touching the door with my hands), and push elevator buttons with my knuckle--all skills learned during SARS in Hong Kong. But a combination of lack of focus, and the fiasco with the US insisting on developing its own test for the COVID-19 virus and flubbing it, has led to serious problems. As late as yesterday, March 15, we’ve been reading reports in our local paper and on social media (see for example here) of people displaying coronavirus symptoms but not being tested because they do not meet some criterion. They perhaps came from Toronto, but not Italy, so are not eligible for the test. The problem is that from a public health point of view, we need to test everyone with symptoms so we can contact others who might have been infected. And there does not seem to be much contact tracing here in the US.

Taiwan is getting some attention for its success in limiting the epidemic, though it would be getting a lot more attention if it were part of the WHO. An article in the Journal of the American Medical Associationonline notes first, how early authorities moved to test visitors and suspected cases. 

On December 31, 2019, when the World Health Organization was notified of pneumonia of unknown cause in Wuhan, China, Taiwanese officials began to board planes and assess passengers on direct flights from Wuhan for fever and pneumonia symptoms before passengers could deplane. As early as January 5, 2020, notification was expanded to include any individual who had traveled to Wuhan in the past 14 days and had a fever or symptoms of upper respiratory tract infection at the point of entry; suspected cases were screened for 26 viruses including SARS and Middle East respiratory syndrome (MERS). Passengers displaying symptoms of fever and coughing were quarantined at home and assessed whether medical attention at a hospital was necessary.

China only began to take action by classing COVID-19 as a notifiable disease on Jan. 20, and shutting down Wuhan on Jan. 23.

Taiwan’s quick and effective reaction was possible because they have highly centralized immigration records and a National Health Insurance Administration (AKA "universal healthcare"), and were able to link the two databases. Though 850,000 Taiwanese live and work in China, and many came back to Taiwan for the Lunar New Year on Jan. 25, the health authorities could identify who had traveled from China within the previous 14 days and could contact them for testing. Taiwan’s household registration system also allows authorities to locate residents; the US has no such system. In Taiwan, and Hong Kong, they have the data and the will to trace contacts; this does not seem to be the case in the US. In Hong Kong and Taiwan, they also monitor people by tracking their cell phone, something that will probably not be politically possible in the US. But I had assumed tracking contacts of people who come down with COVID-19 would be standard procedure in the US, as it was in Asia for SARS in 2003, and is currently the case in Asia. But as I mentioned, they are not even testing many of the people who show coronavirus-like symptoms, let alone tracing contacts. The first case in Missouri was a student who took the train from Chicago on March 4, and came down with symptoms on March 6th. They did disinfect the entire train.

Many people are expecting the epidemic to end with warmer weather, as happens with the flu season. Unfortunately, the fact that there are coronavirus cases in Singapore, which is on the equator, and that the Spanish Flu actually first emerged in June-July of 1918, make this unlikely. (The seasonality of the flu is actually an interesting scientific puzzle.)

Frozen food section at Trader Joe's 

 The panic in the US really hit on Thursday March 12, when there were runs on supermarkets. The panic buying of toilet paper has been widely reported, and my local supermarket had empty shelves; even paper dinner napkins were all gone. Especially surprising was the fact that all the white vinegar was gone! Back in January 2003, Hong Kong newspapers carried stories that mocked Guangzhou people for clearing stores of vinegar, because “superstitious” people were boiling vinegar to prevent what later was known as SARS. Just two months later, there was also a run on vinegar in Hong Kong, as the illness spread to the region. So it is a bit surprising that I see vinegar also gone from my local supermarket.

Paper products at local supermarket

But there are notable differences in cultural ideas of how to quarantine. In Hong Kong, people were encouraged to keep windows open at home, and go out in country parks to get fresh air. (Many people do not realize that Hong Kong is actually 70% country parks and nature reserves.) In California, starting tomorrow, people are required to stay in their homes. It seems to me that it is very safe to go outside as long as there are no crowds, but that is not the advice we are being given in St Louis. We are expected to stay indoors; in Hong Kong, fresh air was believed to be healthy.

The most notable difference in how COVID10 is dealt with is with masks. In Hong Kong, everyone is expected to wear a mask when outside. In the US and Singapore, one is only to wear a mask if ill. The argument is that a surgical mask does not help much in preventing catching the virus. (Here is a brief and insightful anthropological analysis of the different beliefs surrounding masks.) Of course, most people operate on the “better safe than sorry” principle, so would wear masks if they could. But they have been unavailable in St Louis since late January. And now we learn from the NY Times and Wired that there are people who have been buying up masks and hand sanitizers since January, to sell them on eBay and Amazon at a steep markup. This should be the topic of a future (economic anthropology) blog posting, but for now, I'll just say that it adds to the chaos and distrust.

My 90-year mother-in-law lives near Seattle in a retirement home. When asked how she was doing, with all this worry about coronavirus, she said that she has seen so many things in her life, this does not scare her that much. After all, she lived through the Japanese occupation of Hong Kong during WWII, the Cold War and "Red Scare." Yes, this is serious. But with organization and care, societies can get through this.