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The new CDC guidance regarding mask use has seemingly propagated confusion and consternation in comparable measure.
The confusion might have been avoided with better communication and choreography involving other stakeholders - and is thus an unnecessary and unfortunate liability. The consternation in response to a long awaited and much welcome sign that we are headed toward light at the end of our pandemic tunnel is ostensibly surprising. But then again, we haven’t managed to agree about much since all this began.
I have spent most of the pandemic out on a proverbial limb, so I will chance it again now: I fully support the CDC policy inviting the fully immunized to go about much of our business mask free, with one critical proviso.
For starters, let’s look at the liberalization of masking policies (I can’t help but note the irony that “liberalizing” COVID policies tends to be opposed by liberals and supported by conservatives; something seems amok with our nomenclature) through the often clarifying lens of analogy. What I have in mind is: taking a shower.
Every year in the United States, well over 230,000 people visit an emergency department because of injury sustained while…taking a shower. The usual mechanism, of course, is a fall courtesy of a slippery, soapy floor. That’s more than 600 emergency department visits every day- from showers. More than 6000 people die yearly in the U.S. due to falls, and most of those are in the bathroom.
Accordingly, we might all adopt the practice of wearing a helmet in the shower. But to the best of my knowledge, just about no one does.
Why? Because we routinely accept there is a trade-off between managing risks immanent to our daily routines, and living our lives. At some point, risk reduction offers diminishing returns while the costs in inconvenience and discomfort rise. Where those lines cross may be an overt calculation or a covert one; public, as in the case of EPA thresholds for various environmental toxins, or personal - but the way we all live indicates clearly and emphatically that for all of us- the lines cross somewhere.
I am a Preventive Medicine specialist; I know the data on risk better than most. I nonetheless take my chances every day, and shower without a helmet. I do don a helmet, however, when on a bike, skis, or my horse.
One other item about shower helmets: we might imagine that for whatever reason, shower injuries had become a signature issue of public health and the media alike. We might imagine those 600 injuries a day all making national news. We might accordingly imagine some degree of panic over the menace of personal hygiene, and in response - the routine adoption of shower helmets. Industry, of course, would respond with accommodating designer helmets doubling as shower caps. (Maybe I’m onto something?)
My point, simply, is that if we lived in a world where everyone had grown used to shower helmets as a default - it would be hard to stop. We might hear that new materials made shower floors safer, or that new non-slip soaps were available now- but it might nonetheless be hard to talk us all out of shower helmets after we had all talked ourselves into them.
The logical among you have no doubt perceived the principal flaw in my analogy (all analogies are imperfect; you are welcome to perceive other flaws as the spirit moves you): we would wear shower helmets to protect ourselves; we wear COVID masks mostly to protect others.
Accordingly, we might note that heart disease kills more of us - every year - than COVID killed over the past year; that lifestyle factors are the main causes of heart disease; that diet is the single most salient of those; and that how we eat influences how others in our social networks eat (and vice versa). In other words, if we feel compelled to wear masks to avoid transmitting COVID to one another (even when we are unlikely to have it), we might feel compelled to eat well to avoid transmitting bad habits and propagating heart disease. In other words: we might accept responsibility for “second hand junk food” as we have done for “second hand smoke.” To my knowledge, the notion has never received any serious consideration.
Now, let’s move on to COVID and masks.
As noted, we learned to wear masks to protect ourselves a little, and others a little more than ourselves. Mask use always made sense to me - even before it made science (we might invoke the adage, “trust, but verify”). Eventually, it made science as well as sense, although not the one particular form of science a boisterous tribe contends is the only way humans can know what’s what: the randomized controlled trial. While it might be hard to randomize people to wear a real mask or a placebo mask, it strains credulity to randomize people to encounter exclusively others who unfailing do, or unfailingly do not, wear masks.
The resultant paucity of RCT data on the matter notwithstanding, we may be confident that wearing masks will help wearer a bit, and others a bit more.
But that’s all mask wearing was ever about: adjusting risk levels down, a bit. Because mask wearing was a very partial defense, it came with other recommendations about distancing, personal hygiene, and being generally careful and prudent about the intimacy, size, duration, circumstances and composition of any congregating.
Those precautions still make sense; gathering intimately, for an extended period, in a crowded space, at close quarters, to sing and shout and sweat, with a large group of unfamiliar people of unknown COVID status - would be ill-advised for the highly risk averse, whatever your immunization status. So…don’t do that.
As for more prudent encounters, they come in many flavors. You might limit the most “intensive” encounters- indoors, close proximity, extended timeline, such as having dinner together - to people you know, or at least trust. I’m not sure why you would want to be having dinner with people you don’t know in any event, but COVID prudence would argue against it. When encounters are not intensive - when they are brief, at a distance, or outdoors – the risk of COVID transmission is relatively low. Similarly, if you limit your more intimate fraternizing to people you know well, whom you trust to take the same precautions as you - risk of transmission will be extremely low (or at least: predictable, if you are all among the willfully unimmunized).
Transmission of viruses is always somewhat dose dependent, and all of those factors - time, distance, air flow, group composition - affect potential exposure dose, along with the probability of any exposure in the first place.
What’s clear about the vaccines after months of real-world empiricism is that they work as hoped if not better. They slash the risk of any COVID infection in the fully immunized to a tiny fraction of what it was before, and they slash the risk of severe infection to an extremely remote improbability.
The bottom line here is simply this: the risk of getting COVID if you are immunized and even nominally reasonable in your behaviors is very low with or without masks. The risk of getting severe COVID is all but vanishingly improbable.
Others wearing masks might make some incremental addition to your self-defense, and you wearing a mask might make a lesser one still - but these are in the realm of a rounding error. In comparison, it would make a lot more sense to wear a helmet in the shower. And yet, I bet you won’t.
Accordingly, I fully support the CDC policy regarding masks – and see a range of advantages in it. The new policy validates the value of immunization; it rewards vaccination; it reassures that the steps we are taking lead back to something like life as we knew it; and it might encourage those on the fence to get vaccinated.
But, as noted, that support comes with one critical proviso. All of this should be timed to ensure that everyone wanting to be immunized has had the chance.
Absent that, this all becomes rather problematic. Imagine that Person A is eager to be vaccinated, but has not yet been able to access a COVID vaccine. Person A is careful and cautious, and among other pandemic proprieties, wears a mask routinely. But under the new guidance, Person B, who is disinclined to be vaccinated, goes mask free because…who will know? An encounter - in the supermarket, say - between Person A and Person B might now elevate Person A’s risk of COVID. That, to me, seems unreasonable so long as the risk of COVID transmission is above that of other common pathogens.
In other words, the right time to lift mask mandates is either when (a) everyone who wants to be immunized has had that opportunity; or (b) when transmission rates for SARS-CoV-2 have receded into the “background noise” of ambient infectious disease epidemiology, whichever comes first. That is likely soon, but may or may not be now.
The right threshold, however, is not- and cannot be- the absence of all risk.
I am reminded of an exchange between Marlin and Dory in Finding Nemo. Marlin states that he doesn’t want anything to happen to his son, meaning anything ‘bad,’ to which Dory responds: “well you can’t never let anything happen to him; then nothing would ever happen to him- not much fun for little Harpo.”
She had a point. We were never inclined to stay in our homes, or wear a mask at all times, because someone we might encounter in our daily routine had opted out of the, say, measles vaccine. Those of us so inclined got ourselves vaccinated, and then took the residual risk associated with potential exposure without thinking or worrying about it. SARS-CoV-2 infection post full immunization is also a low, non-zero risk.
What of people who choose not to be vaccinated mingling with others who have gone unvaccinated, and then winding up with a nasty infection that might have been avoided? That is a voluntary risk, and people engage in those – beginning with breakfast in America - routinely.
We will need to reconcile ourselves again to the idea that living involves risk. We faced some risk of adversity, including of the infectious variety, on any given day before the pandemic. We might now choose to spend our lives going nowhere, doing nothing, or wearing Hazmat suits in the hope that nothing ever happens to us- but it wouldn’t be much fun.
There is, as ever, a balance to strike between careful protection of our lives, and living them. Our best hope for unmasking sensible pandemic policies resides there.
David L. Katz, MD, MPH, FACPM, FACP, FACLM, is the Founding Director (1998) of Yale University’s Yale-Griffin Prevention Research Center, and former President of the American College of Lifestyle Medicine. He has published roughly 200 scientific articles and textbook chapters, and 15 books to date, including multiple editions of leading textbooks in both preventive medicine, and nutrition. He has made important contributions in the areas of lifestyle interventions for health promotion; nutrient profiling; behavior modification; holistic care; and evidence-based medicine. David earned his BA degree from Dartmouth College (1984); his MD from the Albert Einstein College of Medicine (1988); and his MPH from the Yale University School of Public Health (1993). He completed sequential residency training in Internal Medicine, and Preventive Medicine/Public Health. He is a two-time diplomate of the American Board of Internal Medicine, and a board-certified specialist in Preventive Medicine/Public Health. He has received two Honorary Doctorates.
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