Telling Health’s Story | The National Mask Mandate and Its Surrounding Controversy

News Feature
The National Mask Mandate and Its Surrounding Controversy
Cathy Whang

As more than 73 million Americans watched the first presidential debate, they heard President Donald Trump denounce the use of masks. “I don’t wear face masks like him,” Trump said about President-elect Joe Biden. “Every time you see him he’s got a mask. He could be speaking 200 feet away… and he shows up with the biggest mask I’ve ever seen.”  To this, Biden responded, “Masks make a big difference… The head of the CDC said if we just wore masks and socially distanced between now and January, we’d probably save up to 100,000 lives.”

President Trump was negative for coronavirus the night of the debate but tested positive only two days later. His refusal to wear a mask likely exposed many others. Whereas mask use has been frequent in Asia prior to COVID-19, its use in America was not as frequent and as a result, there were many discrepancies regarding the effectiveness of masks.

Trump’s opinion regarding mask-wearing and its efficiency is shared by millions of others in our country, attributing to the rise in case numbers. However, President-elect Joe Biden’s call to implement a form of national mandate has gained a lot of traction.

According to the CDC Data tracker, the U.S. has recently surpassed 14.6 million cases and 280,000 deaths from COVID-19. These numbers will only exacerbate with the upcoming flu and holiday season, making it critical that masks are strictly enforced and mandated across all 50 states.

Our country needs a national mask mandate; but realistically, public health power lies within the states and not the federal government. Therefore, the title of a “national mask mandate” is rather misleading; but mask policies and mandates must be implemented nationwide via the states.

The Biden-Harris transition team has posted on their website that the future administration plans to call upon every governor to make mask-wearing mandatory in every state, have local authorities reinforce the state orders and encourage Americans to continue wearing masks outside their households.

A national mask mandate, though difficult to enforce, “is the easiest and cheapest way for us to reduce transmission, bend the curve to slow down the virus and bring it under control,” says Linsey Marr, Ph.D., a civil and environmental engineering professor at Virginia Tech and expert in the airborne transmission of infectious disease.

During the early stages of the pandemic, Americans were advised not to wear masks by the U.S. Center for Disease Control (CDC) and World Health Organization (WHO), stemming from the shortage of personal protection equipment (PPE) for frontline healthcare workers and the lack of evidence that masks could protect healthy people. It was only on April 3, 2020, that the CDC and White House Coronavirus Task Force finally started recommending non-medical mask usage for the general public to reduce the transmission of COVID-19. Recent studies at the time had introduced the concept of asymptomatic individuals and their significance in the spread of the virus.

Yet, Trump continually failed to emphasize the emerging importance of masks, refusing to endorse them and wear one himself.

“In light of these studies, the CDC is advising the use of non-medical cloth face covering as an additional voluntary public health measure,” said President Trump during a press briefing on the same day, April 3, 2020. “They suggested it for a period of time, but this is voluntary. You don’t have to do it. I don’t think I’m going to be doing it.”

To appreciate the importance of masks, we must understand how the virus spreads. Marr uses the analogy of cigarette smoke to explain Brownian motion, the movement of particles that creates COVID transmission. When we talk and breathe, we expel microscopic droplets, known as aerosols, which carry the virus and travel through the air like cigarette smoke, farther than six feet. The plume is more concentrated closer to the person who released the “smoke”; indoors, poor ventilation provides more opportunity for other people to breathe them in and become infected.

Though the effectiveness of masks is variable, the bottom line is that masks, even if non-medical, are successful in reducing the transmission across populations via the amount of virus the wearer spreads.

“In the Western world, the dominant discussion about the use of masks comes from healthcare where you’re talking about frontline workers in high-risk situations and it’s N95 or bust,” says Marr. “But we’ve seen that cloth masks are at least partially effective at blocking the virus. I think it’s a very different objective to reduce the spread in the community, compared to protecting healthcare workers.”

Discovering that homemade and cloth masks could also block the virus reduced the pressure on PPE supplies. People stopped reaching for medical-grade N95s, surgical masks and KN94s, as cloth masks, gaiters and bandanas were becoming more acceptable and in fact, encouraged for public use.

Studies done since the pandemic began have revealed that masks reduce the amount of virus exhaled rather than inhaled, hence the common courtesy narrative that we wear masks to protect others around us. According to research that Marr and her colleagues have published online, while cloth masks have low filtration efficiencies for smaller aerosols, double layering fabric can significantly increase the filtration rate by more than 90 percent in aerosols larger than 0.5 μm.

“We’ve been looking at different types of cloth masks and what we found is that they’re not great at filtering out the size of the smallest size aerosols that N95 can capture, but they’re pretty good at getting the larger ones that we think are important for transmission,” says Marr. “Even a cotton t-shirt mask will filter out half of the aerosols that are a medium or larger size and almost every material and every type of mask, even a thick bandana, actually works surprisingly well.”

Marr practices what her research has revealed. Despite having access to all the top personal protective equipment in the world, she still chooses to wear a cloth mask out in public. There is huge variability in the efficacy of non-medical grade masks but as Marr stresses, cloth masks, bandanas and gaiters, with the right combination of layers, material and fit can be on par with an N95 mask.

But not all researchers agree on cloth masks’ value. A team at the University of California, Davis who were studying aerosol particle emissions found cotton mask emission rates were either unchanged or increased relative to no mask. According to their study published in Nature late September, surgical masks and KN95 masks reduced outward particle emission by 90 and 74 percent, respectively, corroborating pre-existing evidence of the efficacy of medical-grade masks, while emission rates for homemade cloth masks either remained unchanged or increased by as much as 492 percent.

Yet that study could not fully assess the efficacy of homemade cotton masks, due to an inability to differentiate fabric particles from respiratory particles. Researchers still encourage people to wear them.

“Mask wearing reduces the transmissibility of someone who is unknowingly infected and maybe doesn’t know that they’re infected, by reducing how much virus they put out into the air and therefore the number of people that they are going to infect,” says Nicole Bouvier, MD, an author of the study and associate professor of infectious disease at Mount Sinai’s Icahn School of Medicine.

The politicization surrounding masks has prompted people to doubt the efficacy and filtering rates of masks. Those who refuse to wear masks often employ the excuse that masks are a threat to health and society.

During a mask mandate hearing held at West Palm Beach, Florida in July 2020, anti-maskers denounced masks, variously claiming that God gave us a respiratory system, therefore we cannot cover it; masks are a crime against humanity; and masks kill people by disrupting oxygen flow and forcing them to rebreathe carbon dioxide.

Hearing these claims, researchers at the University of Miami Miller School of Medicine, Miami Veterans Administration Medical Center and Jackson Memorial Hospital ran a study evaluating how the use of a surgical mask affected gas exchange in people with chronic obstructive pulmonary disease (COPD), who are more prone to retaining carbon dioxide. 

There were no major physiological changes while wearing a mask, proving gas exchange was not significantly affected even in patients with COPD, according to their study published in Annals of the American Thoracic Society in early October. The study recognizes the discomfort that comes with mask use but attributes the perceived difficulty of breathing to psychological phenomena such as anxiety and claustrophobia and reactions due to the increased temperature in a highly thermosensitive area. The authors assure there is no physiological threat or changes in carbon dioxide or oxygen levels when wearing surgical masks, and attests to the safety of masks.

“We don’t believe it kills people because if that were true, how many doctors will have died by now because they’re using these masks,” says Michael Campos, MD, author of the study and an assistant professor at the University of Miami School of Medicine. “Hours of surgery wearing these masks and nothing has happened.”

Campos adds that the findings for surgical masks are not the same for N95 masks as they have been found to increase partial carbon dioxide levels due to their tight fit and lack of airflow, though without major physiological effects. In fact, according to Campos, N95s should not be used for more than 30 minutes at a time, providing yet another reason why the general public should not be wearing these masks.

Mask-wearing, though it should not be political, seems to be extremely polarizing. Our own president’s skepticism of mask-wearing has driven the politicization of the issue, making many Americans reticent to embrace a practice that would be one of the easiest and cheapest ways to manage the pandemic.

The slight discomfort of wearing a mask should not be mistaken for a violation of our personal freedom, but rather should be seen as a civic duty to help positively contribute to our society.

While some are fine wearing masks to protect themselves and others, others refuse to wear masks claiming it is uncomfortable, ineffective and is not mandated by law. However, as Bouvier says, “the politicization of mask-wearing is unfortunate because viruses don’t care whether you’re a Democrat or Republican.”

As our country approaches the winter months, holiday gatherings and increased indoor activity will contribute to the second wave on top of the existing flu season. The Southern Hemisphere which just exited its winter months had practically no flu at all, indicating that the precautions against COVID-19 such as mask-wearing, hand washing and social distancing are all applicable to the flu and more importantly, effective.

Currently, masks are mandated in 37 states, but that is not enough. Dr. Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases, is also pushing for a national mask mandate to help get the pandemic under control.

Researchers at the University of Washington’s Institute for Health Metrics and Evaluation revealed that if a national mandate were in place, it could save nearly 130,000 lives from late September 2020 to February 2021, according to their late October publication in Nature. Yet, they found that in September, only 49 percent of Americans reported that they “always” wear a mask in public.

President-elect Joe Biden has emphasized mask-wearing as a patriotic duty and hinted at a national mask mandate during his campaign, though later acknowledging would not be possible to enforce.

However, on Thursday, December 3, 2020, following the spike of 200,000 new infections the previous day, Biden announced a request to the American people to stop the spread of the coronavirus, just shy of the nationwide mask mandate.

“On the first day I’m inaugurated, I’m going to ask the public for 100 days to mask,” said Biden. “Just 100 days to mask – not forever, just 100 days. And I think we’ll see a significant reduction.”

The U.S. has been experiencing a sharp rise in COVID-19 infections with the highest amount of cases and deaths than any other country in the world. People must come to understand that their civil liberties are not infringed upon by wearing a mask. Rather, we are working to protect ourselves and others to pull the nation out of one of the hardest challenges it has been presented yet. We should seek and heed the advice of health experts as they are working tirelessly, exerting their knowledge and expertise to help us fight a pandemic, which has taken the lives of over 282,000 Americans too many.

The bottom line is that though their efficacies may differ, masks, social distancing, staying at home and washing your hands all work. A patch of overlapping mandates and policies for mask-wearing should be enforced for while some people may think masks are a hoax, human lives are not.

Student Highlight: Cathy Whang, from Long Island, NY, graduated from Emory in May 2021 with a major in Human Health. Her interests in the healthcare field include maternal and child health, as well as increasing access to healthcare. She is taking two gap years before applying to medical school and working as a medical assistant at a dermatology clinic in hopes of gaining experience and understanding the intricacies of medicine to a higher degree. She wrote this piece for HLTH 385W in Fall 2020 during her senior year.