NOTE: The following shall fully supersede any positions taken or advice given prior to August 1, 2020, and shall remain in effect until further notice.
As we now finally enter the endgame of the COVID-19 pandemic in the USA, and face mask mandates are now entering in their third, fourth, or even fifth month in many places, we at the TSAP feel it is time to start talking about how long these mandates shall last, and to what extent, before they are ultimately phased out. Yes, you read that right. There, we finally said the heresy out loud now, and we don't regret it.
While the TSAP has enthusiastically supported fairly broad mask mandates from late April onwards, that support was predicated on these policies being temporary, logical, and nuanced. We have never supported permanent mask mandates (or ones that last until that ever-elusive vaccine), nor have we supported ones that apply to any places that are both not open to the public and and not workplaces (such as private residences and exclusive members-only clubs). Nor have we supported any outdoor mask mandates that last for more than two weeks, unless an exception is made for situations where six feet of distance is possible to maintain between people. And we have opposed all mask mandates that apply to children under two years of age, and have not (yet) taken a position on whether children between the ages of two and ten years of age should be required to wear masks in public either. And penalties for individuals, if any, should not exceed a small civil fine similar to a parking or traffic ticket, with no criminal record. After all, for most people, not wearing a mask is no more dangerous to others than speeding is.
We have generally considered New York State's mask mandate, and later California's, to be a good model for the nation. In contrast, the local ones in Miami and Broward County, Florida, are too broad and harsh by our standards. But even the very best of such mandates should still ultimately have a sunset clause.
Our current position is the same as before, with the following changes:
- All broad mask mandates should sunset no later than January 1, 2021 at the latest, or six months after they began, whichever occurs first. Even in areas currently designated as "red" zones (i.e. characterized by seriously widespread community transmission of the virus).
- In areas that are currently designated as "yellow" or "green" zones, all broad mask mandates should sunset no later than November 4, 2020 (i.e. the day after Election Day).
- Narrow mask mandates, covering only very selected situations such as inside retail shops and/or public transit, can last beyond the end of broad mask mandates, but after November 4, 2020 shall sunset no more than an additional 90 days later in any case.
- Until the November 2020 election is over, masks should remain mandatory at all election locations and on all public transit, even if masks are no longer required elsewhere.
- Going forward, all new broad mask mandates imposed after August 15, 2020 should only be imposed on areas with seriously widespread community transmission of the virus. Otherwise, no new mask mandates.
Of course, in the event of a severe second wave in the winter, these mandates may very well need to be reimposed, and nothing written here shall preclude that, but the TSAP doubts very much that will happen, since "herd immunity" is likely to be reached nationwide by then if it hasn't already. Yes, really.
As for children under the age of ten, the TSAP now believes that after August 15, 2020 they should be completely exempt from any mask mandates, with the possible exception of public transit and within 100 feet of a polling place, in which case only children under the age of two should be exempt.
Furthermore, deaf people and those communicating with them, and anyone for whom wearing a mask is medically contraindicated, should also be automatically exempt from such mandates.
As for children under the age of ten, the TSAP now believes that after August 15, 2020 they should be completely exempt from any mask mandates, with the possible exception of public transit and within 100 feet of a polling place, in which case only children under the age of two should be exempt.
Furthermore, deaf people and those communicating with them, and anyone for whom wearing a mask is medically contraindicated, should also be automatically exempt from such mandates.
Face masks do work to an extent in slowing (not stopping) the spread of the virus when used properly, though their effectiveness has likely been overstated and they should not be regarded as a talisman or a substitute for social distancing and hygiene, but as an additional modest layer of protection when they are widely used by the vast majority of people. They protect those around the wearer more so than they do the wearer. The "effect size" of universal mask wearing is relatively high when there is a high level of widespread community spread of the virus (i.e "red" zones), while it becomes practically negligible when the level of community transmission is at a very low baseline level (i.e. "green" zones). And outdoor transmission is relatively rare with or without masks, while at least 99% of transmission occurs indoors. Thus, the TSAP's nuanced position makes sense now.
Interestingly, none of the Nordic countries (including Sweden) ever saw the need to mandate the use of face masks, nor did the Netherlands, and yet they did not do any worse overall in terms of the the pandemic compared with other European countries that did (often belatedly) require them. On the other hand, all of the East Asian success stories did involve widespread mask wearing, though not every country required it and often it was voluntary. So unlike lockdowns, which turned out to be unequivocally counterproductive and thus worse than useless, the jury is basically still out on the effectiveness of mask mandates when looking at the international evidence.
(The debate on masks, after all, is well over a century old. Really nothing new under the sun here.)
Make no mistake, mask mandates are NOT lockdowns, and are nowhere near as bad. After all, the TSAP supported them as a way OUT of lockdown. But they do come with their own downsides too, and as the weeks turn into months and the months turn into years, they don't exactly age very well either.
UPDATE: It looks like there is yet another nuance to the centuries-old debate about the effectiveness of masks. That is, the latest theory is that even though masks (especially cloth masks) are only partially effective as PPE and source control, they do likely reduce the viral load, which while it can still be somewhat infectious it would would make the wearer and those around them less sick and less likely to die than receiving a higher dose of the virus. A lower dose of the virus is easier for the immune system to knock out quickly before it gets bad, while still enabling the infected to build some immunity going forward. After all, "the dose makes the poison", and indeed the etymology of the word virus comes from and old word for "poison". Another way to potentially reduce viral load is to gargle with an alcohol-based mouthwash regularly. That said, these nuances do not materially change the TSAP's position, and in fact reinforces our middle-of-the-road approach.
Of course, to avoid further concentrating one's own potential viral load, be sure to change or clean your mask very regularly, and don't wear it 24/7 with no breaks. Fresh air is also a good thing too, after all. That is, use common sense!
And this begs the question once more to the lockdown enthusiasts who at first opposed masks but later embraced them: if masks are so effective, why did we even lockdown at all? Seriously, why did we?
Interestingly, none of the Nordic countries (including Sweden) ever saw the need to mandate the use of face masks, nor did the Netherlands, and yet they did not do any worse overall in terms of the the pandemic compared with other European countries that did (often belatedly) require them. On the other hand, all of the East Asian success stories did involve widespread mask wearing, though not every country required it and often it was voluntary. So unlike lockdowns, which turned out to be unequivocally counterproductive and thus worse than useless, the jury is basically still out on the effectiveness of mask mandates when looking at the international evidence.
(The debate on masks, after all, is well over a century old. Really nothing new under the sun here.)
Make no mistake, mask mandates are NOT lockdowns, and are nowhere near as bad. After all, the TSAP supported them as a way OUT of lockdown. But they do come with their own downsides too, and as the weeks turn into months and the months turn into years, they don't exactly age very well either.
UPDATE: It looks like there is yet another nuance to the centuries-old debate about the effectiveness of masks. That is, the latest theory is that even though masks (especially cloth masks) are only partially effective as PPE and source control, they do likely reduce the viral load, which while it can still be somewhat infectious it would would make the wearer and those around them less sick and less likely to die than receiving a higher dose of the virus. A lower dose of the virus is easier for the immune system to knock out quickly before it gets bad, while still enabling the infected to build some immunity going forward. After all, "the dose makes the poison", and indeed the etymology of the word virus comes from and old word for "poison". Another way to potentially reduce viral load is to gargle with an alcohol-based mouthwash regularly. That said, these nuances do not materially change the TSAP's position, and in fact reinforces our middle-of-the-road approach.
Of course, to avoid further concentrating one's own potential viral load, be sure to change or clean your mask very regularly, and don't wear it 24/7 with no breaks. Fresh air is also a good thing too, after all. That is, use common sense!
And this begs the question once more to the lockdown enthusiasts who at first opposed masks but later embraced them: if masks are so effective, why did we even lockdown at all? Seriously, why did we?
OCTOBER UPDATE: A cursory review of the empirical evidence so far reveals that while masks may very well be marginally effective at the micro level, they apparently are practically insignificant at the macro level, at least in the long run. To wit, as the charts here so clearly show, broad mask mandates do not appear to have had any noticeable impact on the course of a country, state, or locality's epidemic curve. To name a few, Hawaii, Illinois, LA, Miami, Kansas, Wisconsin, Israel, Japan, Spain, Argentina, and most notoriously Peru all have seen no beneficial long-run impact on cases (which actually increased at some point after implementation, even in conjunction with strict lockdowns in some cases), and the same was ultimately true for deaths and hospitalizations as well, except for Hawaii, Israel, and Japan whose death rates remain unusually low for reasons not yet fully understood. As for Czechia, the crown jewel of early mask mandates, it appears to have only worked the first time in conjunction with their early suppression strategy in the spring, but not the second time around when the virus came roaring back in the fall. Meanwhile, mandate-free Sweden, Denmark, Norway, North and South Dakota, Georgia, and the parts of Florida without local mandates don't seem to have had worse trends overall. Thus, the TSAP no longer officially supports broad mask mandates as of October, except perhaps for a limited time (two to three weeks) in locally-defined "red zones".
And we certainly do NOT support any federal mask mandates in the USA at all, period. They are not only constitutionally dubious at best, but as noted above there is simply not nearly enough evidence in their favor to justify such unprecedented federal government overreach even temporarily. Fortunately, even Joe Biden himself has largely walked back his initially strong support for such federal mandates.
NOVEMBER UPDATE: On November 18, 2020, the much awaited Danish mask RCT study was finally released and published three months late in the Annals of Internal Medicine. And the results were, shall we say, rather underwhelming, and not statistically significant (i.e. not statistically different from null). Not necessarily the final word, but hardly a ringing endorsement for the effectiveness of general mask use in the community at the macro level.
A recent Cochrane review of the literature is not exactly reassuring either, to put it mildly.
But what about source control, you say? That is, protection of people around the wearer, which most studies were not designed to look at? Again, a cursory look at the data in the weeks and months following the implementation of mask mandates don't really support that either, at least not at a general population level. Thus any such community benefit is likely either very small, very transient, or both.
Thus, we can conclude that even if there is some overarching benefit to wearing masks in some situations, universal community masking (or lack thereof) is nowhere near the game-changer it was originally sold as. If it were, the pandemic would have been effectively over in a given locality, state, or country (even as it raged elsewhere) within two or three weeks following the implementation of a broad mask mandate. And that has not happened anywhere in the world, even in places with very high (90%+) compliance, and even when combined with a ban on indoor restaurant dining (a behavior which might vitiate the results). And as of November, the TSAP believes going forward that mask wearing (outside of a healthcare setting) should be largely (if not entirely) voluntary, and that businesses of any kind should be free to decide whether or not to require employees and/or customers to wear them.
Our best advice? "Use masks judiciously, NOT superstitiously", pretty much sums it up.
No one actually knows when this pandemic will really end because there are so many factors involved.
ReplyDeleteTrue, no one knows for sure. But an honest epidemiologist can make fairly good guesses. By the way I made some updates to this article. Enjoy!
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