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.

The ambiguity of discrimination

Last week I stopped briefly at the supermarket to pick up a few items. When I was done, I approached the checkout counters from the far end of the supermarket, passing stations 17, 16, and 15 that were closed. In most American supermarkets, each checkout counter is really in a lane, flanked on both sides by "impulse purchases" like candy and tabloid newspapers and scandal magazines. The checkout lanes have tunnels of about 5 meters before the conveyor belt actually begins. I saw that stations 14 and 13 both had their lights on, meaning they were open, and as I came up to 14, I looked down the tunnel and saw the cashier handing the customer the receipt, so I knew I could enter and immediately get checked out. As I turned down the lane for counter 14 and got ready to put my few items from my cart onto the conveyor belt, I heard a voice from the other side of the tunnel (in lane 13) say, "I can also take you over here." I looked up and saw the head of a blond woman speaking to me; she was the cashier from lane 13, walking in her "tunnel", perhaps re-arranging the candy on the shelves. Since there was no one in front of me, and especially since my cashier in lane 14 was African-American, I was not about to switch lanes. That would have required backing up and going around the candy and magazine racks to enter her lane. My daughter had just emailed me two days earlier with a story in the NY Times about the rules readers "of color" follow to avoid being harassed by security or store attendants, rules like "don't throw away your receipt before you leave a shopping center," "put your American Express Platinum Card next to your driver's license so a police officer will see it when they ask for an ID" and "do not wear a large purse or many layers of clothes when you walk into a store." So I was not about to switch lanes. I just started putting my items on the conveyor belt. After I had put my items on the conveyor belt and walked up to the cashier, the cashier from lane 13 said to my cashier, "They never see you when you're old."

I was stunned. She thought I was discriminating against her for being "old." I had barely seen her face, did not know her age or think of her as "old," and was not thinking about that at all. I was concerned about not appearing to discriminate against an African American, but more importantly, I just took the first empty lane! I was mostly trying to save time. The cashier in lane 13 apparently did not realize that I could not actually see that her lane was empty as I approached the checkout counters; because of the "tunnels" of impulse items, I could only see each lane as I came up to it. I had taken the first empty lane.

In this photo, I returned to the scene days later. Lane 14 is not open this day, but you can see that one cannot see the cashier over the displays.

From my point of view, it is clear I was not discriminating against an old person, but maybe other people do discriminate. And this is what makes claims of discrimination so difficult to prove. I can easily dismiss this instance, but I cannot say that it never happens. Indeed, I suspect that the cashier in lane 13 has probably experienced some discrimination, which led her to impute discrimination in me. It would be easy for me to accuse her of being oversensitive, or of imagining things. But that would be missing the point. People who do not experience discriminatory treatment can easily dismiss it, and not admit even when it really does happen.

I sheepishly told my cashier, "I just took the first empty line." She just smiled.

On Loving and Racism

June 12, 2017, was the 50^th anniversary of the US Supreme Court decision Loving v Virginia, which overturned a Virginia state law making interracial marriage illegal. It finally eliminated all such racial bans across the US. There was considerable interest in the case in the US (see for example here and here). 

Mildred and Richard Loving

The case involved a white man, Richard Loving, who married a woman, Mildred Jeter Loving, who was of mixed African and Native American descent. They grew up in a mixed race community, and knew each other because Richard was friends with Mildred’s brother, with whom he shared an interest in car racing. Interracial marriage was illegal in Virginia at the time, so they had gone to Washington DC to get a marriage license. Shortly after they were married, they were arrested in July 1958, in the middle of the night, by an eager sheriff. They avoided jail by agreeing to leave Virginia, but were homesick in DC and so, with the help of civil rights lawyers, and even though they did not seek to be activists, they appealed their case all the way to the Supreme Court. Fifty years ago, in a unanimous decision that reversed decades of legal precedent for anti-miscegenation laws, the Lovings won their appeal and were free to live in marriage in Virginia.

One aspect of the story that few people realize, and that I was not aware of growing up in the US, is that these racial laws are not that old. The law used against the Lovings was the “Racial Integrity Act” of 1924. I understood that the laws were “an instrument of ‘White Supremacy’”, as Chief Justice Earl Warren had written in his unanimous opinion, but I did not understand, growing up, that these laws had to be strengthened and reinforced to continue to mark the lines between the races, and indeed to create the lines. Many earlier laws had been repealed from the 1860s to the 1880s (e.g. in Illinois, Michigan, and Washington). Similar laws were repealed in 15 states between 1948 and 1965, in many cases probably because they also discriminated against Asians (California in 1948, Indiana 1965; see full list here). The Loving v Virginia case overturned anti-miscegenation laws in the remaining 16 states, mostly in the Deep South.

Many articles celebrating Loving Day, as it has become known, comment on the increase in frequency of interracial marriage. According to Pew, the rate has increased from 3 percent in 1967 to 17 percent today. Public opinion has changed too: according to a University of Chicago GeneralSocial Survey poll, only 14 percent of nonblack adults say they are “very or somewhat opposed” to a close relative marrying a black person, compared to 63 percent in 1990. (Of course, this is what they say to pollsters; the real number is likely to be higher, since there is strong social pressure to be non-racist--which is actually good.)

But it is worth looking more closely at these figures. First of all, it is striking that whites are the group with the lowest rate of intermarriage, just 11 percent, compared to 18 percent for blacks. For Asians, it is 29 percent, and for Hispanics it is 27 percent. Even more striking is that 39 percent of US-born Hispanics and almost half (46 percent) of US-born Asians marry outside their group.

As an aside, black men are twice as likely as black women to marry outside their group (24 vs 12 percent), while Asian women (36 percent) are much more likely that Asian men (21 percent) to marry out. (See details from Pew here).

Since whites are the larger group, it is perhaps not surprising that mixing is less common than in the minority groups. But I wonder if a good deal of the intermarriage is within “people of color” and thus not having as much effect on whites as might be assumed.

Furthermore, much of the supposed intermarriage may be between people who are already “mixed” themselves. A Eurasian man, born to an Asian mother and white father, will legally be considered Asian (the US government defines race matrilineally), but may not be treated as “Asian” in white American society. His marriage to a “white” woman will not raise as many eyebrows as his mother’s marriage may have.

Similarly, a white man married to a Cuban-American woman may be considered a “mixed marriage” because she checks the box as “Hispanic,” but in terms of phenotypic appearance, it is possible she could pass for white… or at least as Italian. It may not really be considered by their families as a "mixed marriage."

The issue is really a matter of our definition of “race” and culture. In a NY Times article printing reminiscences of mixed marriages, many wrote about “cultural differences.” If the couples grew up in different countries, or in different subcultures within the US, this may be an issue. But the story of Loving v Virginia is about “race,” not about culture; it is about not being able to marry because of what one looks like. The whole issue of race in America is confused, and intermarriage is making it more so. “Hispanics” are recognized as an “ethnic group” but are put on the same order of difference as “race.” Yet clearly a Hispanic’s experience in the US will be different depending on whether they are an Argentine who looks white like Lionel Messi (or the Pope) or a Dominican who looks black and indigenous like the baseball player RobinsonCanó. 

Gradually, American definitions of “race” have to change. Chief Justice Earl Warren had questioned the notion of a “pure race” in his questions to the lawyer for the state of Virginia, but the final decision did not address that issue, focusing just on the idea that anyone should be able to marry whoever they want. As one commentator points out, it is unfortunate that the Supreme Court did not challenge the very concept of race.

I am uncomfortable with the hope for more interracial marriage as a solution to America’s racial problems. It sounds like the inverse of eugenics, and it does not really address the racism at the root of discrimination. Racism is a cultural idea; it does not spring naturally from physical differences. There are  Yet, confusing categories does serve a purpose. We can call this the Sneetches Theory of antiracism, after the Dr. Seuss story of Sneetches with stars on their belly who discriminated against those who did not have a star. Technology to add and remove the star created confusion of categories, after which all lived happily together (see video of the story here). My father served in Puerto Rico during WWII, and he told me segregation in the military seemed ridiculous because brothers, with the same mother and father, would be assigned to “white” or “Negro” units, based on their physical appearance and the mood of the officer in charge on that particular day. Clearly “race” was a problematic category, and it undermined attempts to “keep them in their place.”

But ultimately, racism will be defeated through cultural change, not biological change. As in the story of the Sneetches, only when people agree to drop the categories will racism be overcome.

I heard a disturbing interview with Pat Buchanan on This American Life. Buchanan was asked how he felt that he had run for president three times in the 1990s and lost, but Trump took most of his ideas and won. (He said he was fine with it, happy the country is being saved.) In the interview, he defended his anti-immigrant position, a basically racist view, saying the country is already too divided, so the US should not let in non-white immigrants. He claims they do not assimilate. He thinks the US was better before 1960 when it was “majority European white” and when asked why he is against immigration, he says “I feel more comfortable with the folks [I] grew up with.” Until Trump’s election, these views were dying out with Buchanan’s generation. It remains to be seen whether the racism of the Alt Right is the last gasp of the reactionaries, or will be strengthened and emboldened by the Trump administration. In any case, I find it surprising and disappointing that intelligent people like Buchanan can say such racist things, fifty years after Loving v Virginia.