Face coverings for covid-19: from medical intervention to social practiceBMJ 2020; 370 doi: https://doi.org/10.1136/bmj.m3021 (Published 19 August 2020) Cite this as: BMJ 2020;370:m3021
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Psychosocial, biological, and immunological risks for children and pupils make long-term wearing of mouth masks difficult to maintain
IIn a recent article, Westhuizen and colleagues  argued for a global implementation of face covering to control COVID-19 virus spread. In doing so, they do not differentiate between adults, adolescents, and children. This rapid response considers the negative effects at the immunological and psychological level of mandating facemasks for children and adolescents and maintains that they outweigh the possible gains.
1. SARS-COV-2 infection and transmission in children and adolescents is low
Infections with the virus SARS-COV-2 can occur in children and adolescents. The course of the disease is often mild or asymptomatic. In exceptional cases, severe Covid19 symptoms can occur in children or adolescents with underlying diseases. In a number of studies of hospitalized children with Kawasaki syndrome or multiple inflammations, there is a suspicion of a relationship with SARS-COV-2 infection, but this has not been unequivocally proven; antibodies and / or a positive rtPCR test were not detected in all patients . Analyses by the Karolinska and Pasteur Institute concluded that children and adolescents are unlikely to be the main spreaders in the Covid19 pandemic [4-6]. Contamination from children to parents or teachers is sporadic. To date, the risk of infection appears to be greatest in the home situation, nursing homes and hospitals. In Sweden, where facemasks are not used in schools and schools even remained open during the first wave, as in other countries, the number of older people in intensive care has dropped from June to a few per week. Despite the recent increase in “Covid19 infections” in many other countries, only a small increase in Covid19 patients in intensive care units can be observed.
2. Facemasks at school: a slippery slope from virus protection to mental breakdown?
Reducing virus contamination using facemasks remains a topic of heated debate among scientists and policy makers [6-9]. At the outset of the pandemic, WHO experts advised that use of facemasks is not recommended as potential benefits are rather limited and there is a potential risk of self-contamination if used improperly. Moreover the WHO stated in their report of June 5 “At present, there is no direct evidence (from studies on Covid19 and in healthy people in the community) on the effectiveness of universal masking of healthy people in the community to prevent infection with respiratory viruses, including Covid19  Contamination of the upper respiratory tract by viruses and bacteria on the outside of medical face masks has been detected in several hospitals . Another research shows that a moist mask is a breeding ground for (antibiotic resistant) bacteria and fungi, which can undermine mucosal viral immunity. This research advocates the use of medical / surgical masks (instead of homemade cotton masks) that are used once and replaced after a few hours . This means that a family with 2 children and 2 parents who go to work by public transport and do their shopping will consume 20 facemasks per day (€ 25 / day, € 9,000 / year per family). Today, facemasks are considered an easily enforceable low-cost measure when 1.5 m social distance cannot be respected, in unventilated areas or in the presence of immunocompromised patients. Limited experimental and observational studies report a reduced risk of SARS-CoV2 virus transmission of 6-80%: the effectiveness varies greatly depending on the type and quality of the masks, the basic contamination level of the studied population, laboratory test used, and epidemic context [7-9, 13-14].
Aside from the highly variable protective effects, WHO mentions several negative aspects of frequent / long-term use of facemasks, fuelling the debate as to whether the benefits outweigh the drawbacks .
Many people report claustrophobic experiences and difficulty getting sufficient oxygen due to the increased resistance to inhaling and exhaling. This can lead to an increased heart rate, nausea, dizziness and headaches and several other symptoms [15,16]. In an inquiry among Belgian students wearing mouthmasks for one week, 16 % reported skinproblems and 7 % sinusitis, Also problems with eyes and headaches and fatigue were frequently mentioned . Furthermore, face masking can provoke an increase in stress hormones with a negative impact on immune resilience in the long term . Facemasks prevent the mirroring of facial expressions, a process that facilitates empathetic connections and trust between pupills and teachers. This potentially leads to a significant increase in socio-psychological stress. During childhood and puberty the brain undergoes sexual and mental maturation through hormonal epigenetic reprogramming [18-21]. Several studies show that long-term exposure to socio-psychological stress leaves neuro-epigenetic scars that are difficult to cure in young people and often escalate into mental behavioural problems and a weakened immune system [22-26]. A recent study by the CDC concludes that in young adults (18-24 years), the level of anxiety and depression has increased by 63% (!) since the corona crisis. A quarter of them think about suicide. As a result, the use of antidepressants has increased by 25% . Several researchers have shown a relationship between the increase in stress experiences and the risk of upper respiratory tract infections and mortality [28-31].
3. A healthy diet and lifestyle for young people is more important than ever in the context of Covid19
At this moment the health protective benefits of non-professional use of facemasks are doubtful . Hence, we argue for a less one-sided focus on facemasking, paying more attention for healthy lifestyle and psychological well-being [33-35] Especially for children and young people from families with a low economic status, malnutrition or chronic illnesses, explicit government support is requested  Attention to underexposed but important preventive nutritional support including vitamins D and C is needed to increase the anti-viral immune resistance, control disease and virus spread [37-39]. Complementary integration of healthy nutrition and lifestyle measures will further allow to reduce comorbidity risks (obesity, diabetes, CVD) for severe covid19 infections, which at long term will contribute to improved health and reduction in healthcare costs and promote resilience for a healthier society [36-39].
Prof. dr. Wim Vanden Berghe
Department Biomedical Sciences
PPES Lab Proteinchemistry, Proteomics & Epigenetic signalling
Prof. dr. Mattias Desmet
Faculty Psychology and Educational Science
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2. Toubiana J, Poirault C, Corsia A, Bajolue F, Fourgeeand D, Augoulvant F et al. Kawasaki like multisystem inflammatory syndrome in children during covid-19 pandemic in Paris. France prospective observational study. BMJ. 2020;3091. Doi.org/10.1136/bmj.m2094.
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17. Hal JMF, Cruser D, Podawiltz A, Mummert DI, Jones H, Mummert ME. Psychological stress and the cutaneous immune response: role of the HPA axis and the sympathetic nervous system in atopic dermatitis and psoriasis. Dermatol. Res. Practi 2012;2012:403908. Doi:10.1155/2012/403908. Doi: 10.1155/2012/403908
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19. Toro CA, Aylwin CF, Lomniczi A, Hypothalamic epigenetics driving female puberty. J Neuroendocrinol, 2018. 30(7): p. e12589.
20. Lomniczi A, Ojeda SR. The Emerging Role of Epigenetics in the Regulation of Female Puberty. Endocr Dev, 2016. 29: p. 1-16.
21. Notterman DA, Mitchell C. Epigenetics and Understanding the Impact of Social Determinants of Health. Pediatr Clin North Am, 2015. 62(5): p. 1227-40.
22. Essex MJ, Boyce T, Hertzmann C, Lam LL, Armstrong JM, Neumann SMA. Epigenetic vestiges of early developmental adversity: childhood stress exposure and DNA methylation in adolescence. Child Dev, 2013. 84(1): p. 58-75. doi.1111/j. 1467-8624.2011.01641.x
23. Bhopal S, et al., The contribution of childhood adversity to cortisol measures of early life stress amongst infants in rural India: Findings from the early life stress sub-study of the SPRING cluster randomised controlled trial (SPRING-ELS). Psychoneuroendocrinology, 2019. 107: p. 241-250.
24. Cunliffe VT. The epigenetic impacts of social stress: how does social adversity become biologically embedded? Epigenomics, 2016. 8(12): p. 1653-1669.
25. Bush NR, Edgar RD, Park M, MacIsaac J:, McEwan LW, Adler NE et al. The biological embedding of early-life socioeconomic status and family adversity in children's genome-wide DNA methylation. Epigenomics, 2018. 10(11): p. 1445-1461. doi. 10.2217/epi-2018-0042
26. Gudsnuk K, Champagne FA. Epigenetic influence of stress and the social environment. ILAR J, 2012. 53(3-4): p. 279-88.
27. Young Adults’ Pandemic Mental Health Risks. https://www.nytimes.com/2020/08/24/well/family/young-adults-mental-healt.....
28. Prior A, Tenger-Gron M, Larsen KK, Larsen FB, Robinson M, Nielsen MG et al. The Association Between Perceived Stress and Mortality Among People With Multimorbidity: A Prospective Population-Based Cohort Study. Am J Epidemiol, 2016. 184(3): p. 199-210. doi.10.1093/gje/kwv324
29. Wieduwild E Girard-Madoux MJ, Quatrin L, Laprie C, Chasson L, Rossignol R et al. beta2-adrenergic signals downregulate the innate immune response and reduce host resistance to viral infection. J Exp Med, 2020. 217(4). doi: 10.1084/jem.20190554
30. Nielsen NR, Kristensen TS, Schohr P, Gronbaek M. Perceived stress and cause-specific mortality among men and women: results from a prospective cohort study. Am J Epidemiol, 2008. 168(5): p. 481-91; discussion 492-6. doi: 10.1093/aje/kwn157
31. Calder PC, Carr AC, Gombart AF, Eggersdorf M. Optimal Nutritional Status for a Well-Functioning Immune System Is an Important Factor to Protect against Viral Infections. Nutrients, 2020. 12(4). doi.10.3390/nu12041181
32. Jefferson T, Heneghan C. Masking lack of evidence with politics CEBM.2020. www.cebm.net/Covid-19/masking lack of evidence with poltics
33. Kim S-W, Su K-P. Using psychoneuroimmunity agains COVID-19. Brain Behavior and Immunity 27 (2020) 4-5. doi.org/10.1016/j.bbi.2020.03.05
34. Lazzari D, Bottacioli AG, Bottaciolo F. Letter to the Editor Kim S-W, Su K-P. Using psychoneuroimmunity against COVID-19. Brain Behavior and Immunity 27 (2020) 4-5. doi.org/10.1016/j.bbi.2020.03.025
35. Arshad MS, kahn U, sadio A, Khaldi W, Hussain M, Ysaween A et al. Coronavirus Disease (COVID-19) and Immunity Booster Green Foods: A Mini Review. Food Sci Nutr, 2020. doi.org/10.1002/frsn 31719
36. Wolfson JA, Leung CW, Food Insecurity and COVID-19: Disparities in Early Effects for US Adults. Nutrients, 2020. 12(6).
37. Richardson D, Lovegrove L, Nutritional status of micronutrients as a possible and modifiable risk factor for COVID19: a UK perspective. British journal of nutrition, 2020.
38. Godlee F. Covid19: What we eat matters all the more now. BMJ 2020; 370: m2840 | doi.org/10.1136/bmj.m2840
39. Holuka C, Merz MP, Fernandes SB, Charalambous EG, Seal SV. The Covid-19 pandemic: does our early life environment, life trajectory and socio economic status determine disease susceptibility and severity? 2020. Jul19;219140:5094. Doi: 10.3390/ijms21145094
Competing interests: No competing interests
The emergence of an extraordinary situation like the COVID-19 pandemic may be a once-in-life situation for all of us. To survive this pandemic and emerge out of it, is the main concern at the individual, community, national, and global levels. We are still to discover successful treatment and vaccination for the deadly SARSCoV 2 virus. By the time the clinical trials provide us with the results, we have to rely on the existing measures like hygiene and physical barriers to prevent transmission of infection. However, these existing and proven to be successful measures need to be of high quality to be effective.
The World Health Organization has changed its stance on masks over time in this pandemic. This has led to diverse interpretations and varying policies from country to country on the use of masks. Although public health agencies in most countries now recommend mandating face-covering against COVID-19, there are no studies comparing various types of masks for face covering in the community settings. Facemasks are primarily a source control measure but are also useful in protecting the wearer from the infection. We read with great interest the article on face-covering inspired by social practices (1). However, the social practices of face-covering cannot be relied entirely upon and are not as effective as medical masking. Cloth masks and dupattas do not form the three layers recommended for masking and do not necessarily seal the mouth and nose areas to avoid the spread of droplets. Cloth facemasks are not subject to regulation and vary widely in layer number, size, and quality.
A randomized controlled trial of 1600 healthcare professionals found a significantly higher rate of all infection outcomes in the cloth mask arm, with the rate of influenza-like illness being 13 times more in cloth mask arm and lab-confirmed viral infection being 1.72 times more in cloth mask arm compared to the medical mask arm (2). This study also reports more than double the penetration of particles by cloth masks than the medical mask (97% vs. 44%). Another study also reported a high penetration of particles through cloth (40-90%) (3). There is also evidence to suggest that the rate of infections decreases as the quality of masks improves (4-6). In a recent systematic review of 172 observational studies (of which 30 studied the masks) across 16 countries and six continents in healthcare and non-health-care settings (n=25,697 patients). N95 face or similar respirators were more effective in reducing the risk of infection compared with disposable surgical masks or similar (e.g., reusable 12–16-layer cotton masks) (4).
Without an RCT, it is unclear whether cloth masks provide clinical protection at the community level against COVID-19. This pandemic is an opportunity to study cloth mask's effectiveness that has become popular in developing and developed countries due to government policies.
Since the coronavirus SARS-CoV-2 pandemic has caused significant mortality and morbidity across the globe, we suggest that social norms alone cannot be relied upon for patient awareness and adherence to masking. Moreover, it is human nature to resist the change in social behaviours, more so in older adults. Social resistance to use of vaccines by certain sections of society is an important example in this regard. It is also dependent upon individual beliefs and attitudes. Rules and regulations need to be modified based on scientific research and not merely social comfort and practices. The new rules can then be expected to become part of cultural practices for a long-term impact. Standard guidelines need to be enforced for use of face mask, the type and number of cloth layers recommended, the area around the nose and mouth that need to be covered, etc. The masking should be recommended as the best medical preventive measure, and the community must be encouraged to use it. COVID-19 vaccine, once available soon, may not be affordable to all. In addition, its effectiveness and safety cannot be predicted. In such circumstances, the mask is a cost-effective and readily available option as the cheapest social vaccine. Administrative and healthcare resources need to be directed to community-level medical masking as behavioral change based on medical evidence for months to come as virus is here to stay and vaccine is still miles away!!
Jasmine Parihar, Rajinder K Dhamija*
Department of Neurology, Lady Hardinge Medical College and Associated Hospitals, New Delhi ,India
* Corresponding Author
1. Van Der Westhuizen HM, Kotze K, Tonkin-crine S, Gobat N, Greenhalgh T. Face coverings for COVID-19: from medical intervention to social practice. BMJ 2020; 370 :m3021
2. MacIntyre CR, Seale H, Dung TC, et al. A cluster randomised trial of cloth masks compared with medical masks in healthcare workers. BMJ Open. 2015;5(4):e006577. Published 2015 Apr 22. doi:10.1136/bmjopen-2014-006577
3. Rengasamy S, Eimer B, Shaffer RE. Simple respiratory protection—evaluation of the filtration performance of cloth masks and common fabric materials against 20-1000 nm size particles. Ann Occupat Hyg 2010;54:789-98.
4. Chu DK, Akl EA, Duda S, Solo K, Yaacoub S, Schünemann HJ. Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: A systematic review and meta-analysis. Lancet 2020;395(10242):1973-1987. https://doi.org/10.1016/s0140-6736(20)31142-9
5. MacIntyre CR, Wang Q, Cauchemez S, Seale H, Dwyer DE, Yang P, et al. A cluster-randomized clinical trial comparing fit-tested and non-fit-tested N95 respirators to medical masks to prevent respiratory virus infection in health care workers. Influenza Other Respir Viruses 2011;5:170-9.
6. MacIntyre CR, Wang Q, Rahman B, Seale H, Ridda I, Gao Z, et al. Efficacy of face masks and respirators in preventing upper respiratory tract bacterial colonization and co-infection in hospital healthcare workers. Prevent Med 2014;62:1-7.
Competing interests: No competing interests
Face coverings" are not the proper masks for the pandemic: More matters of reading (the WHO guidance) rather than hearsay
How did we come to this point: neo-liberalism in a misguided stance against cultural dogmatism and gender subjugation in a pseudo-alliance with right-wing nationalism and sovereign citizen movement in defiance of public health orders and medical advice, all in opposition to wearing face masks?
The fact is cultural face covering is not face masks for the purpose of infecton control for COVID-19 pandemic. Even as the WHO belatedly issued its interim guidance in June 2020 in a shift of its position from March 2020, they discourage the use of medical-grade masks, suggesting their use for healthcare workers and people who have symptoms suspected to be COVID-19 related (Ref 1).
Despite this, the WHO also did provide guidance on non-medical mask standards for use by the general public in the pandemic; referring to "the French Standardization Association (AFNOR Group) to define minimum performance in terms of filtration (minimum 70% solid particle filtration or droplet filtration) and breathability (maximum pressure difference of 0.6 mbar/cm2 or maximum inhalation resistance of 2.4 mbar and maximum exhalation resistance of 3 mbar)", they discussed specifically the material used, number of layers, combination of material, mask shape, coating of fabric and mask maintenance.
I seriously doubt any cultural face covering will pass the WHO standard for non-medical masks for general use in a pandemic.
However as many nations are caught short by the mismatch of availability of suitable PPE for both healthcare workers and the general public, the narrative from WHO's guidance is translated to a overly simplistic public health advice condoning the use of masks of dubious quality by the public, including home-made varieties where a "something is better than nothing" mentality is passed as adequate self protection. This intital convernience in a simplified public messaging proves to be problematic when it becomes obvious that some home made masks (like the "sock-mask") are totally inadequate and inappropriate in their use even by the general public--at best offering obvious compliance to public health directives with no real protective benefits.
Wearing of masks also become a geo-political hot potato, when those who did wear it in defiance of local health department advice in many countries early in the pandemic, and even now where various national leaders still refuse to acknowledge the pandemic as a serious public health threat in their jurisdiction. Now various parts of the community, tired of restrictions imposed in response to the pandemic, openly oppose all public health directives, including the wearing of masks in public areas.
What would our fore bearers think of our self-inflicted social conundrum regarding the wearing of masks? They would no doubt be shocked by our problem, despite better education and access to services.
Some would point out that there was similar resistance to mask-wearing during another world pandemic often compared to the current COVID-19 crisis: the Spanish Flu of 1918-9 (Ref 2).
And how did this modern healthcare use of face masks start? Medical anthropologists point to the emergence of "plague masks" in 1910 involving the "Manchurian plague epidemic", when "Chinese imperial court appointed as the head of its anti-plague efforts the Penang-born, ethnically Chinese, and Cambridge-educated Wu Liande. Entangled in a struggle that involved the disease itself, local interests, imperial conflict, and wider aspects of social antagonism, Wu adopted the bold theory that the spread of the disease did not require non-human vectors (such as fleas), as rival Japanese scientists insisted, but was transmitted directly between humans in an airborne manner and was therefore contagious." (Ref 3)
The plague mask then "resembled recently established surgical face-worn protective devices (usually dated back to 1897; Spooner 1967) but generally involved more protective layers and a more complex tying process, designed to keep the mask in place while operating in the adverse open-air conditions of winter-time Manchuria" (Ref 3)
Dr Wu's contribution to public health medicine is so significant that it earned him almost a full page obituary in the BMJ, written in part by Sir Philip Manson-Bahr (doyen of tropical medicine and the author of Tropical Diseases: A Manual of Diseases of Warm Climate, still in print as Manson's Tropical Diseases); no mean feat considering Dr Wu's background, work and contributions occurred largely outside Great Britain as it was then.
What would Dr Wu and others (who had experienced the benefits of the pandemic mask) make of our perceived problems with the culture wars?
Apart from being flabbergasted, I suspect their advice would be to wear a proper mask!
Competing interests: No competing interests
Van der Westhuizen et al make the valid and perceptive point that a number of contemporary behaviours are as much sociocultural norms as they are medical interventions (1). The classical example is dental and personal hygiene. They argue that wearing face coverings could eventually fall within this category.
However we do not practise in an apolitical secular vacuum. Some wider cultural cognisance is required. The last decade has seen, in many parts of the world, including in Europe, the controversial introduction of legal prohibitions on the wearing of face coverings; even as part of socio-cultural practices; while still allowing the practice for medical purposes (2). This is a direct obstacle to any aspiration of the cultural propagation of the face apparel in the COVID-19 pandemic.
Aspects of this controversial suite of legislation have been criticised by the United Nations Human Rights Committee (3). The raison d’être may have been to liberate women. However some evidence shows that such laws may merely have served to limit women’s mobility (2,4). In the wake of the COVID-19 pandemic, in some countries the wearing of face masks is now mandatory in public places. Yet the paradoxical situation exists where a woman can be prosecuted for wearing a face covering as part of a socio-cultural practice, but she is spared if it is for the purposes of this new medical “socio-cultural norm”, to stem the spread of communicable disease (5). The cultural appropriation of face apparel cannot be promoted with reticence to this contradiction. There can be no progress toward a world where the wearing of face masks is socio-cultural normality while there exist prescriptions to which socio-cultural norm the behaviour must conform.
(1) van der Westhuizen HM, Kotze K, Tonkin-Crine S, Gobat N, Greenhalgh T. Face coverings for covid-19: from medical intervention to social practice. BMJ. 2020;370:m3021. Published 2020 Aug 19. doi:10.1136/bmj.m3021
(2) Hopkins CT Social reproduction in France: Religious dress laws and laïcité Women’s Studies International Forum 2015:48:154-164
(4) Open Society Justice Initiative 2013 https://www.justiceinitiative.org/uploads/86f41710-a2a5-4ae0-a3e7-37cd66...
Competing interests: No competing interests
According to Deputy Chief Medical Officer, Dr Jenny Harries at Friday’s No 10 news conference “Evidence on face coverings is is [sic] not very strong in either direction”. It is therefore a random way to conduct government to make people have them, and many find them a serious nuisance rather than “supportive”.
Competing interests: AgeofAutism.com, an on-line daily journal, concerns itself with the potential environmental sources for the proliferation of autism, neurological impairment, immune dysfunction and chronic disease. I receive no payment as UK Editor
Esmee S Hanna has carefully dealt with social impact of wearing or not wearing masks and people getting branded as "deviant" for the non-use of the mask.
It transpires from the author's analysis that making rules about where and who should wear a mask and of what specifications will be extremely complicated and difficult. Same will apply to the distancing rules for various places and situations.
*I wish to bring to the attention a very different aspect of the issue. Some people seem to derive peculiar pleasure in purposefully coughing, sneezing and spitting at other people. #
Biomedical, Aerodynamic and any other branches of science can find out what Effects various situations, places, wind direction and speed, ambient temperature, humidity, lighting and atmospheric pressure will have on carriage of droplets and virus particles through air. Sciences also can determine how long the virus can survive in various situations on various surfaces and inside various objects.
These systematic studies may be compiled into easy to understand pictorial graphic and tabular form and published in popular press: newspapers, periodicals and magazines as well as distributed as handouts in schools, colleges workplaces and health facilities so that people themselves will know how to take care of their own safety rather than expecting appropriate behaviour from others.
MBBS, MD; FCGP, FAMS, FICP;
Founder Convener and President:
Our Own Discussion Group,
Consaltant Physician at Ruchi Diagnostic Center and Ruchi Clinical Laboratory, Sunshine CHS,
Maharashtra State INDIA.
Competing interests: No competing interests
Much comment by advocates and opponents of face masks and coverings has focused on the quality and validity of the evidence base, and whether this justifies their widespread use outside clinical settings.1 Face coverings have been presented as a key tool in enabling the reopening of society.2 Notwithstanding ongoing debates about their effectiveness, face coverings are now widely mandated by governments in indoor public spaces. Advocacy for masks has drawn mainly on research conducted in biomedical settings; some scholars have explicitly invoked their medical credentials to justify claims to scientific authority, dismissing the contributions of other disciplines as “sparring” and foregrounding the “moral accountability” of the physician.3 Compulsory policies on face coverings have been introduced primarily on the basis of biomedical evidence, with limited input from other disciplines, for example the social sciences and engineering. Given the challenges Covid-19 has created for society, never has there been a greater need for meaningful interdisciplinary dialogue.
Westhuizen and colleagues’ engagement with ideas beyond the biomedical is therefore heartening.4 However, their social and cultural analysis is problematic. In particular, they ignore or discount important issues relating to the unintended negative consequences of face coverings. Westhuizen et al. note that “as a community adopts face coverings, the first members wearing a face covering will be seen as deviant, but later those without coverings become deviants from the new norm.” In endorsing or even encouraging the characterization of those who do not or cannot wear face coverings as ‘deviants’, they risk reinforcing a troubling trend towards stigmatization of people with a wide range of disabilities. These include, for example, people who are D/deaf5, neurodiverse, or experiencing mental health issues such as anxiety, as well as people who have experienced violence and trauma.6
Early findings from an ongoing study of the experiences of face coverings during the pandemic led by EH7 indicate that the prospect of abuse or stigma due to not wearing a covering (even with a valid exemption) inhibits some people from leaving their homes to conduct essential routine daily activities. A Disability Rights UK survey has found that nearly 70 per cent of disabled people report fear of judgement for not wearing a masks.8 Encouraging a view of mask wearers as “altruistic or even as protectors”—and those who do not wear masks, by implication, as selfish or self-centred—fosters a divisive and damaging binary. It risks forcing public declarations on those with health issues or (dis)abilities through the use of badges, lanyards or exemption cards.9–11 There are disturbing historical examples of such forced self-identification.
Any shift from the medical to the socio-cultural dimensions of face coverings must engage with the moral issues of inequality and social exclusion, including the potential for adverse consequences for marginalized groups, large and small, who stand to be marginalized further. Poverty is a key dimension of the impact of the Covid-19 pandemic.12,13 Public health responses to the Covid-19 pandemic are increasingly commodified in ways that are exclusionary, yet which Westhuizen et al., with their emphasis on masks as a fashion accessory or a tool for projecting self-image, risk appearing to endorse. Examples of designer masks retailing for high prices are abundent,14 yet the study led by EH is discovering the experiences of families struggling to acquire and maintain sufficient coverings to satisfy current requirements for basic social participation.
Consideration of the socio-cultural influences on mask uptake must not ignore its negatives. Thorough assessment of the balance between potential benefits and harms of the intervention is essential, as is examining the distribution of those benefits and harms.12 There must also be clear plans as to when and how mandated face covering will no longer be required: without clear evidence of benefit to begin with, an end point may be difficult to identify.
More fundamentally, any programme based on a socio-cultural analysis must incorporate the reflexivity expected of such analyses. Moral accountability is not the exclusive preserve of the medically-trained. In seeking to reduce the impact of mortality and morbidity from the pandemic, we must not lose sight of other legitimate objectives. While devastating for a minority (including those bereaved or experiencing enduring symptoms), the direct impact of Covid-19 will be limited for others, including most of those infected.15 The indirect harms of the pandemic, including those accruing from interventions designed in response, should not be underestimated. The public, including marginalized groups such as those mentioned above, are more than adopters, resisters and ‘deviants’, or the intended objects of “sociocultural framing.”4 They are stakeholders who should be engaged with and involved in decisions about public health interventions that have socially patterned benefits and harms.12,16
The Roman philosopher Cicero coined the phrase “Salus populi suprema lex esto” to describe the first duty of any legitimate government. ‘Salus’, however, has a much broader meaning than just health, referring equally to the safety, security, welfare and happiness of citizens. Mass interventions such as mandating face coverings must always be justified as conferring benefits proportionate to the harms they may do elsewhere. Without a full and reasoned assessment of this policy, that justification has yet to be made.
1. Jefferson T, Heneghan C. Masking lack of evidence with politics. CEBM. 2020 [accessed 25 August 2020]. https://www.cebm.net/covid-19/masking-lack-of-evidence-with-politics/
2. Greenhalgh T, Sentance A. While other countries are recovering, Britain is the patient in intensive care. The Guardian. 17 June 2020 [accessed 25 August 2020]. https://www.theguardian.com/commentisfree/2020/jun/17/covid-19-britain-i...
3. Greenhalgh T. Masks for the public: laying straw men to rest. Authorea. 2020. https://www.authorea.com/users/316109/articles/446320-masks-for-the-publ...
4. Westhuizen H-M van der, Kotze K, Tonkin-Crine S, Gobat N, Greenhalgh T. Face coverings for covid-19: from medical intervention to social practice. BMJ. 2020;370:m3021.
5. Grote H, Izagaren F. Covid-19: the communication needs of D/deaf healthcare workers and patients are being forgotten. BMJ. 2020;369:m2372.
6. Ferguson D. Rape survivors say they are being stigmatised for not wearing masks. The Guardian. 10 August 2020 [accessed 25 August 2020]. https://www.theguardian.com/society/2020/aug/10/survivors-say-they-are-b...
7. Understanding the experiences of face masks. 2020 [accessed 28 August 2020] https://dmu.figshare.com/articles/poster/Experiences_of_face_masks/12860543
8. Disability Rights UK. 40% fear challenge without face masks - DR UK survey. 2020 [accessed 25 August 2020]. https://www.disabilityrightsuk.org/news/2020/june/40-fear-challenge-with...
9. I can’t lip read through your mask pin badge [accessed 25 August 2020]. https://www.etsy.com/uk/listing/814757722/large-i-cant-lip-read-through-...
10. Sunflower lanyard [accessed 25 August 2020]. https://hiddendisabilitiesstore.com/lanyard.html
11. Face covering exemption card [accessed 25 August 2020]. https://www.firstgroup.com/uploads/node_images/face-covering-exemption-e...
12. Martin GP, Hanna E, McCartney M, Dingwall R. Science, society, and policy in the face of uncertainty: reflections on the debate around face coverings for the public during COVID-19. Critical Public Health. 2020 in press. https://dx.doi.org/10.1080/09581596.2020.1797997
13. Ahmed F, Ahmed N, Pissarides C, Stiglitz J. Why inequality could spread COVID-19. The Lancet Public Health. 2020;5(5):e240.
14. Marriott H. Burberry launches £90 coronavirus face mask. The Guardian. 20 August 2020 [accessed 25 August 2020]. https://www.theguardian.com/fashion/2020/aug/20/burberry-launches-corona...
15. Riley S, Ainslie KEC, Eales O, Jeffrey B, Walters CE, Atchison CJ, et al. Community prevalence of SARS-CoV-2 virus in England during May 2020: REACT study. medRxiv. 2020;2020.07.10.20150524.
16. Dingwall R. Patrician policymaking. Social Science Space. 2020 [accessed 25 August 2020]. https://www.socialsciencespace.com/2020/08/coronavirus-uk-patrician-poli...
Competing interests: No competing interests
It is not surprising that face coverings are a contentious issue. As Trisha Greenhalgh and colleagues comment, wearing a face covering is not simply a case of complying with medical advice . However, something that was not made explicit in this article, is how much of the controversy was caused by the medical community failing to make clear why people were being asked to wear face coverings in the first place.
At the beginning of the pandemic there was considerable "panic buying" of a number of products including toilet roll. Given this behaviour, it made sense not to promote the buying of medical masks by the public, especially as the medical community was at the time experiencing shortages of Personal Protective Equipment (PPE) .
However, what did not help was the impression that the public were being encouraged to make their own PPE at home . As PPE equipment is manufactured and tested to specific standards, it was not surprising that many rightly pointed out that home made masks could never replace properly manufactured and tested PPE. As such the advice to make a home made mask sounded more like an attempt to manipulate the public into i) not panic buying medical masks and ii) think they were at least doing something to protect themselves. This was the reason why many refused to wear masks, adopting the rhetoric of "muzzles" and "government/establishment manipulation".
But, this impression was entirely unnecessary because the argument for wearing homemade (or non-medical) masks should never have been about PPE. Instead the main purpose of wearing a face covering is simply to divert the wearers breath so that if they were an asymptomatic COVID-19 carrier, their breath would contaminate fewer objects (or people). Of course home-made or non-standardised face masks cannot stop the wearer breathing in the virus or indeed breathing the virus out, but it can limit the spread of potentially infectious particles .
As a consequence the messaging should never have been about the public being asked to create second rate PPE, but rather it should always have been clearly about encouraging a specific action that would contribute towards protecting communities from the spread of the virus.
The great tragedy of this story is that while some people understood this, many didn't. The result was that those who did understand had a reasonable argument for accusing those who did not wear face coverings as being selfish, while those who chose not to wear face coverings had a reasonable argument for accusing those who did wear coverings as being guilty of smug virtue signalling (from an ineffective PPE perspective). Unfortunately given the nature of public discourse, as soon as this polarisation started to occur attitudes became entrenched and the dialogue became more heated.
This incident serves as an important lesson as to what can happen when health messaging is unclear. These errors must not be repeated during the next issue appearing on the horizon - that of encouraging public uptake of potential COVID-19 vaccinations.
 BMJ 2020; 370 doi: https://doi.org/10.1136/bmj.m3021
Competing interests: No competing interests