The Pros and Cons of Masks

My Facebook feed is an even mix of those questioning the conventional narrative of donning a mask (and practically everything else related to pandemic) and demeaning or self-righteous pleas to get everyone to wear a mask. Dare I say both sides can learn something from the other? Before a nuanced discussion on the topic, we must first set aside several assumptions.

The first is the assumption that SARS-CoV-2 is the pathogenic factor causing the condition COVID-19. This has been called into question because the RNA nucleoprotein of SARS-CoV-2 has not been isolated, cultured, and proven to be pathogenic upon reinfection according to Koch’s postulates. Furthermore, polymerase chain reaction testing to amplify a fragment of genetic material is only valuable to diagnose a transmittable illness once Koch’s or Rivers’ postulates have been satisfied.

If instead the RNA nucleoprotein of SARS-CoV-2 is an exosome triggering a catharsis of one or more environmental pollutants, then what we are labeling a virus is not the root cause of the disease. Measures to minimize exposure to this emergency signal of the human virome would only distract from the real issue of ecological degradation that is insidiously driving humanity to an extinction-level event. In this instance, the exosome we are incorrectly classifying as a pathogenic virus is nature’s short-term effort to protect humans from long-term calamity.

Whether virus or exosome, it is prudent to challenge the dominant narrative to avoid exposure until a vaccine becomes available. On an individual level, we are all shocked to hear news of a supposedly healthy young individual dying from the coronavirus, but on a collective level, our species has survived because the vast majority of people are exposed to environmental stressors and survive.

In immunology this notion is called herd immunity. Sweden embraced this axiom of human biology and chose not to mandate quarantine as most other countries did this past spring. Instead, citizens were instructed to carry on while only high-risk individuals isolated themselves, in hopes that cresting the curve of herd immunity would safeguard the vulnerable members of the society in the months ahead. It is too early to tell, but initial data suggests Sweden has achieved herd immunity.

Because the concepts of exosomes and herd immunity are matters of theory, we shall proceed with the working assumption that SARS-CoV-2 is the one and only pathogenic cause of COVID-19 and that there is no benefit to exposure, hence the need to flatten the curve as much as possible and wait for a vaccine to be developed.

In that world, cloth masks only provide one subset of protection. They hinder (not eliminate) airborne viral particles others might encounter but do not protect wearer. The only form of personal protection equipment tested to safeguard the wearer are N95 masks.

Reserved for front-line medical professionals, an N95 mask must be tightly worn such that the wearer cannot smell or taste a chemical sprayed into the air. This indicates the mask has been properly fitted against airborne exposure to pathogenic microbes.

The only reason for the average person to don a cloth mask is to protect others. The thin barrier of cloth captures droplets of moisture expelled from exhalation, coughing, or sneezing. These respiratory droplets are heavy enough to drop to the ground within a few feet of expulsion. Hence the recommendation for social distancing, which should have been termed “physical distancing in social solidarity” from the very beginning as “social distancing” is an emotionally toxic term.

Although a cloth mask can help lower the total burden of airborne viral particles, a small RNA nucleoprotein like SARS-CoV-2 has the potential to become aerosolized, travel through cloth masks, and stay suspended in the air (this is still being studied, research here and here). Aerosolized viruses traversed the globe long before international travel and only concentrate when they can attach to particulate matter in the air. In the absence of air pollution, viral particles diffuse evenly in the atmosphere.

This underscores a critical observation: Cities hardest hit with disease burden are regions with considerable air pollution. The conventional explanation is that population density in urban areas accelerates communicable disease transmission, but there are highly urbanized areas with less air pollution that have not been as severely affected.

Whether air pollution itself is a predisposing factor to the pathogenesis of COVID-19 or a proxy for viral concentration, the solution is the same: ventilation. Purification of indoor air via medical-grade HEPA filtration is the only solution for a virus that has become aerosolized. A cloth mask neither protects the wearer nor slows the buildup of aerosolized viral particles.

Thus, maintaining a physical distance of several feet to minimize exposure to respiratory droplets and air purification to remove aerosolized particulate matter should be primary in the hierarchy of controls to stop the spread of disease. Cloth masks are only appropriate when within a few feet of another individual.

This ethic of mask wearing were most sensibly showcased by our family physician. He set up his office such that our family sat several feet away during intake. With no one wearing a mask, we could read each other’s facial expressions and derive the most benefit from the therapeutic encounter. Only when in close quarters for the exam did our doctor slip on a mask.

This is a very different scenario than a person driving around in a car wearing a cloth mask. I’ve even seen a person on a motorcycle wearing a mask but not a helmet. These are laudable efforts (even if misguided), but chronic mask wearing also has cons as well as pros.

Wearing a mask in public reinforces physical distancing but can be problematic if adjusting one’s mask due to discomfort, resulting in increased respiratory exposure to soiled hands.

Although safe for most individuals for short periods of time, wearing a mask may not be appropriate for those with a chronic respiratory disease or those who’ve experienced any physical or sexual trauma that involved suffocation. In the former instance, breathing can become labored wearing a mask, while the latter might trigger a panic attack.

What I’ve been shocked to witness are social media posts publicly shaming those who do not wear a mask. This issue is not as black and white as “Everyone should wear a mask” or “Masks provide no benefit and damage the health of the wearer.” There is a lot of unacknowledged nuance in between those extremes, often with a litany of YouTube videos to support a position.

I recently saw one such video with an angry medical doctor refuting the assertion that masks do not affect oxygen saturation in the body. He affirmed his position by wearing a mask and showing that the readout from a pulse oximeter on his finger didn’t drop below a normal value. His unequivocal message to those opposed to masks: Stop being selfish; masks pose no harm.

My commonsense response is that oxygen saturation need not drop in response to a change in one’s environment or challenge to homeostasis. Someone can have a raging migraine headache and normal oxygen saturation. (Headaches can be triggered by breathing carbon dioxide.)

I listen, ponder, and rely on the experience of my patients. Even among those who do not have a psychosocial objection to wearing a mask, I’ve received several reports of chronic headaches, elevated blood pressure, and anxiety in those wearing a mask all day. These were new conditions that I had not documented in previous care of these patients and presumably not a nocebo effect linked to resentment from wearing a mask as these individuals are in favor of their use.

Cloth masks provide a modicum of benefit for close-quarter encounters (though not a substitution for physical distance and ventilation), but an entire population masking up presents several societal challenges that need to be factored into the equation to derive a balanced perspective.

My grandfather recently passed away from old age and consequences of dementia. He spent the last few months of his life in a care home with very little meaningful human interaction, all of it behind glass or masks and face shields. His jovial and extroverted self suffered; his decline was rapid. He transitioned to hospice care by the time he arrived in the home of a family member. Humanity suffers with the fear perpetuated in the wake of COVID-19, and I’ve heard several similar stories from patients.

I’m concerned about the ramifications on social trust and interpersonal connection in an era of wearing masks. How will children be affected, and will the quality of their education suffer (particularly for those with cognitive impairment, sensory issues, and developmental disabilities)? How does a deaf individual who is reliant on lip reading interact with a masked individual? (Those with a hearing impairment also find it difficult to discern speech muffled through a mask.) These may be asinine questions to ask during a pandemic, but it wouldn’t be the first time society makes a short-term choice with unintended long-term consequences.

Opponents of mask mandates are quick to point out the infringement on personal freedom. This is a slippery slope, and it is possible that efforts to make mask wearing mandatory contain a seed of social engineering. After all, airports have not gone back to pre-9/11 security. There are challenges to humanity and freedom that don’t require a conspiracy to perpetrate.

On a related note, it is worth questioning why mask mandates are being issued when, although cases are increasing (because testing has increased), all mortality involving COVID-19 has been steadily declining since mid-April.

The pros and cons surrounding this polarized issue are not mutually exclusive. Society must adopt a sensible and socially conscious stance on wearing a mask while acknowledging (not denying) the physical, psychological, and societal fallout. Above all else, we must see beyond the veil of sensationalized media and polarized discourse to band together and address our collective biological terrain, psychological resilience, and environmental contributions to this pandemic.