Is it really time to ditch the mask?BMJ 2022; 377 doi: https://doi.org/10.1136/bmj.o1186 (Published 11 May 2022) Cite this as: BMJ 2022;377:o1186
- Rok Hrzic, doctor of philosophy candidate in European public health123,
- Vasco Ricoca Peixoto, public health medical specialist, researcher, and doctor of philosophy candidate345,
- Amanda J Mason-Jones, associate professor in global public health36,
- Alison McCallum, visiting professor of public health37
- on behalf of the ASPHER COVID-19 Task Force
- 1Department of International Health, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands
- 2ASPHER Young Professional, Brussels, Belgium
- 3ASPHER COVID-19 Task Force
- 4NOVA National School of Public Health, Public Health Research Centre, Universida de NOVA de Lisboa
- 5Comprehensive Health Research Centre - Universidade Nova de Lisboa
- 6Department of Health Sciences, University of York, York, UK
- 7Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
The mandatory use of face masks in indoor public areas and on public transport as a mitigation measure to prevent covid-19 transmission was abolished between February and April 2022 in Denmark, Sweden, the Netherlands, and the UK.1 This is in contrast to many other European countries, including Austria, Germany, France, Italy, Portugal, and Spain, that are maintaining face mask requirements in some settings, including on public transport.2 With the omicron BA.2 variant still spreading rapidly, uncertainty about what future variants may emerge, and ventilation related mitigation still limited in many areas, removing all mask mandates may be unwise at this point. Two suggested reasons for this policy shift are the public’s alleged pandemic fatigue and reluctance to carry on with protection measures,3 and the proposal that removing mask mandates provides an opportunity to build herd immunity through widespread infections with omicron.4 Neither of these arguments stand up to scrutiny.
Pandemic fatigue hinges on the idea that the public’s adherence to risk reduction strategies diminishes over time as weariness sets in.56 This theory has often been contradicted by surveys and studies that have found public adherence to protection measures has been high throughout much of the pandemic.7 If the public are, however, now exasperated by pandemic measures,8 it may not necessarily be the covid rules themselves. Instead, populations may have become more sceptical of their governments due to a perceived break in the social contract and a lack of perceived coherence, transparency, communication, or justification for decision making.9 As the writer James Baldwin has pointed out, allegiance must be reciprocal and the public grow weary if it is not.10 The relationship between the public and their government has been undermined by high ranking government officials flaunting rules in the UK and elsewhere,11 the failure to implement adequate ventilation, the lack of clear, consistent guidance on mask wearing where exposure was unavoidable,12 and neglecting to make masks and other measures (isolation and quarantine, for example) financially accessible to all.
The indiscriminate removal of mask mandates exacerbates this disconnect between governments and their citizens by reducing the quality of life and independence of a sizable proportion of the population. We must remember that multimorbidity is common,13 is linked to structural inequity, and increases the risk of severe covid-19 disease.14 For many people, regularly being in high risk indoor spaces such as on public transport, in government buildings, grocery shops, or doctors’ offices is not always optional. By removing widespread mask wearing in spaces that people must use without otherwise minimising levels of exposure, governments are effectively pushing individuals to risk their health and wellbeing. The fact that this de facto exclusion of vulnerable people from public life has been relatively uncontested is only because many societies have already become inured to exclusion, poverty, illness, and the deaths of those most likely to be harmed by covid-19.
For some commentators, the arguably milder omicron variant is perceived as an opportunity to foster herd immunity through infection and offset the lagging global vaccination effort.4 However, it is always preferable for herd immunity to be a product of high vaccination coverage, particularly as it also reduces the risk of long term covid-19 complications and sequelae (long covid).15 Many European countries have large sections of the population who are unvaccinated, including people in high risk occupations and facing economic deprivation, with data showing that there are often socioeconomic gradients in vaccine uptake.161718
While previous covid-19 infection seems to provide protection against acute reinfection with omicron, it has a limit and we do not yet know how long this lasts.19 Despite the high prevalence of omicron infection this winter, the later BA.2 sublineage spread rapidly in Denmark20 and the UK, maintaining high case numbers, pressure on healthcare services, and social disruption. It is therefore highly uncertain how much protection current infection with omicron could provide against any future variant. Furthermore, infection, regardless of the variant involved, exposes people to the risk of long covid, the burden and prevalence of which we are still seeking to fully understand.212223
The data we have so far show that masks are effective in preventing transmission, particularly indoors.24 However, effectiveness increases with the proportion of people wearing them.25 Masks are among the most effective non-pharmaceutical measures we have for covid-1926 but are not consistently adopted by communities, hindering clear impact assessment.27 In addition, insufficient investment in outbreak investigation, contact tracing, and reporting have made it harder to capture the protective effect of masks in real world settings.
The decision to lift any covid-19 mitigation measure should be made through a transparent, inclusive, and evidence based process of public debate28 considering the accountability for reasonableness framework (which sets out a fair process for decision making involving publicity, relevance, revisability, and enforcement). Decision making should explicitly consider every person’s right to be protected from avoidable and reasonably foreseeable harm, aim to reduce discrimination, and enhance individual autonomy.
Widespread mask use should remain part of the arsenal that helps us to protect people’s health and reduce the social and economic burden of covid-19, especially if new variants emerge that present a higher disease risk and put increased strain on healthcare services. It will be difficult for governments to backpedal now and reintroduce mask mandates in public and crowded indoor places. But the current policy will allow covid-19 to spread more easily, increasing the harmful effects of covid-19, including perpetuating inequities and exclusion. To blunt these harms, European governments should make a sustained effort to demonstrate the added value of wearing masks in high risk indoor spaces with large population mixing, while seeking to mitigate the environmental impact of disposable masks and make mask use financially accessible to all.
Acknowledgments: We acknowledge the contributions and endorsement of the manuscript by Ralf Reintjes, Sharmi Haque, Ines Siepmann, Flavia Beccia, Laurent Chambaud, Jean-Philippe Naboulet, John Reid, Nadav Davitovitch, and other members of the ASPHER COVID-19 Task Force.
Competing interests: None declared.
Provenance and peer review: Not commissioned; not peer reviewed