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Face coverings for covid-19: from medical intervention to social practice

BMJ 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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Socio-cultural reflections on face coverings must not ignore the negative consequences

Dear Editor

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.

References
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

28 August 2020
Esmée S Hanna
Reader, Health and Wellbeing in Society
Robert Dingwall, Margaret Mccartney, Robert West, Ellen Townsend, Jackie Cassell, Graham Martin
De Montfort University
6.09 Edith Murphy Building, De Montfort University, Leicester, LE1 9BH