Editor’s note: This commentary is by Dr. Turner Osler, a career academic trauma surgeon at the University of Vermont Medical Center turned research epidemiologist.
The entire public health community is in agreement: Not only do masks work, but they are our single best protection against the Covid-19 pandemic. Yes, there has been pushback, but this has been largely political theater. Health care workers on the front line, a group who are scientifically inclined, well informed, and who risk their lives every day on our behalf, demand PPE. And the PPE that we provide our health care providers work — even when doing procedures that provoke coughing in patients who are actively shedding virus, few health care providers have become infected.
But if masks are such a great solution, why does the pandemic continue to rage across America?
Well, most obviously, not everyone in America is wearing a mask. This is a serious problem that makes getting control of the pandemic impossible, but it is a large topic for another commentary.
Here I want to emphasize that even if everyone were masking up routinely, a mask is only effective if it is worn correctly. And unfortunately, wearing a mask correctly is not easy. I have a good deal of experience with wearing masks, because during my long career as a surgeon I wore masks many hours a day, every day. I wear glasses, and for the first few years I had to carefully tape the top edge of my mask to my nose to keep my breath from leaking under the top edge of my mask and fogging my glasses. Eventually I learned to bend the stiffener along the top edge of my surgical mask just so, and I was able to forgo my mask taping ritual.
So I understand that how to wear a mask well isn’t obvious. And actually, here at the University of Vermont’s medical center we require everyone who wears an N95 mask take a brief course and demonstrate that they can arrange their mask in a way that provides a secure seal around the entire perimeter. It may seem obvious, but if your mask doesn’t make a complete seal around its edge you will be breathing unfiltered air, leaving you as vulnerable as if you were wearing no mask at all.
A recent paper out of Denmark published in the Annals of Internal Medicine failed to show that surgical masks mailed to Danish citizens protected them. But the design of the masks used failed to make an effective seal with the face. Perhaps more problematically, almost no one in Denmark wears masks, so no one else was wearing masks. For masks to be effective, everyone must wear them, both the (possibly asymptomatic) person shedding virus and those around him/her who might contract the virus. What this experiment showed is that poorly fitting masks worn by few people are ineffective. So, this study really makes the case for effective masks worn properly; half measures will not succeed.
The business of getting one’s equipment just right because your life depends upon it is well known to rock climbers, scuba divers and skydivers, but this imperative is unfamiliar to people outside the realm of extreme sports. And it’s a heavy lift to make that point that a mask isn’t a fashion statement; it’s a piece of equipment on which your life, and the lives of those around you depend.
How can we help everyone in America wear their mask in a leak-free way so that they, and everyone around them, is well protected? Well, perhaps making it clear that a well-fitting mask is, quite literally, a matter of life and death. And many lives are on the line: not just the life of the person wearing the mask, but also the lives of everyone around them.
So, there’s the whole “life and death” argument. Then it’s mostly a matter of being willing to adjust, and re-adjust, and if necessary re-re-adjust one’s mask until when one exhales all of one’s breath passes through the mask fabric rather than out under the edges of the mask. I can say from experience that while it takes a little practice to get one’s mask adjusted just right, eventually muscle memory takes over and it becomes a habit.
Now the bad news: Many, perhaps most, of the masks I see each day not only are not worn well, but they cannot be worn well. Certainly, bandanas make no attempt to seal with the face. But really any mask that lacks a stiffener along the top edge that confirms to the bridge of the nose will similarly fail to make an airtight seal with the face. Even surgical masks equipped with an upper edge stiffener often fail to make a good facial seal with the perimeter of the face if held in place by ear loops; straps around the head are much more reliable. And, really, this isn’t surprising: Surgical masks were designed for the operating room, with the goal of capturing surgeons’ sneezes; they were never designed to prevent viral transmission by aerosols.
What’s really needed are N95 masks. These masks have been around since the 1970s, so the design has been thoroughly tested. They are designed not only to filter air effectively, but to fit the human face exactly. Briefly put, we need not only to wear our masks better, but also to wear better masks. We’re going to be wearing masks for some time to come; it only makes sense to wear our masks as though our lives depended on them. Because they do.