Frozen in Place
Our crisis of inertia as revealed by our continuing reliance on cloth masks
Last March, I wrote a short article in the New York Times calling for universal masking, including using homemade masks as a stopgap measure to deal with the shortages. There was a lot of skepticism around cloth masks at the time, so we got together as a team of 18 experts to provide a review of evidence that cloth masks—especially if they were multi-layered and well-fitting—were a perfectly acceptable means to fight the pandemic. We found that masks were especially useful as ‘source-control’; they were useful in protecting others from the wearer. “Your mask protects me; my mask protects you,” was the slogan. We wrote the paper and submitted it to a prestigious academic journal.
And then came the twists and turns of peer-review. It took about nine months from start-to-finish to get the article out. As usual, most of that time was taken up just waiting for the review to come back from editors with revisions, and then for our revised paper to be re-reviewed. To be fair, the peer-review process, although slow, made the paper better! Plus, we had, of course, made the preprint version publicly available, and it has already been cited 170+ times as a preprint—including in Nature, Science, The Lancet, etc. And the open preprint review process has been great, too! The paper is much improved, and the preprint itself is the most downloaded preprint on the service it was placed.
The paper, if I do say so myself, remains an excellent contribution. It reframes the question of masks around protecting healthcare workers from getting infected, but perhaps more importantly, it also explains how source control—dampening transmission from person-to-person—is important for controlling epidemics.
But here’s the problem: the paper should not have been this relevant in January of 2021. Maybe it could be relevant as a reframing of source control, sure. As a nice line in my academic CV? Yes, please! But as something people still reference to understand why even homemade cloth masks can work even though the virus itself is tiny and even travels in aerosols? It should have been outdated.
It seems like, philosophically and epistemologically, we keep making two simultaneous errors when it comes to pandemic. The errors seem like they are contradictory, but they are actually closely related through inertia. First, we make the perfect the enemy of the reasonable and available. People were arguing that, since medical-grade respirators were in short supply wearing masks was pointless. Well, we wrote the paper to counter that wrong-headed argument.
And then, as everyone knows, first the CDC and then the WHO pivoted. They recommended that cloth masks be worn, after all. Fine! Better late than never, right? Unfortunately not; nine months later, people are still wearing cloth masks, with no guidance on how to wear them, and no way to purchase the specific multi-layer ones that we know perform better.
The WHO has technical guidance on how cloth masks should be made, including what the layers should be. Here’s a small excerpt from it:
Homemade non-medical masks
Homemade non-medical masks made of household fabrics
(e.g., cotton, cotton blends and polyesters) should ideally
have a three-layer structure, with each layer providing a
function (see Figure 1) (168). It should include:
1. an innermost layer (that will be in contact with the face)
of a hydrophilic material (e.g., cotton or cotton blends of
terry cloth towel, quilting cotton and flannel) that is nonirritating against the skin and can contain droplets (148)
2. a middle hydrophobic layer of synthetic breathable nonwoven material (spunbond polypropylene, polyester and polyaramid), which may enhance filtration, prevent
permeation of droplets or retain droplets (148, 150)
3. an outermost layer made of hydrophobic material (e.g.
spunbond polypropylene, polyester or their blends),
which may limit external contamination from penetrating
through the layers to the wearer’s nose and mouth and
maintains and prevents water accumulation from
blocking the pores of the fabric (148).
Although a minimum of three layers is recommended for nonmedical masks for the most common fabric used, single,
double or other layer combinations of advanced materials
may be used if they meet performance requirements. It is
important to note that with more tightly woven materials,
breathability may be reduced as the number of layers
increases. A quick check may be performed by attempting to
breathe, through the mouth, through the multiple layers.
I’ve no problem with the guidance except that it’s obviously completely impractical. How are people supposed to try to figure this out at home? How are millions of people supposed to juggle these requirements and find appropriate hydrophobic material for the middle and the outer layer. How many people even know what spunbond polypropylene, polyester and polyaramid are?
There are other, good recommendations in the guidance, but they are not within reach for the ordinary home-mask sewer.
Why on earth, nine months after the pandemic’s onset in this country, are people trying to make masks at home? Or buying random versions from random sellers on Etsy or Amazon or other companies that have nary a certification?
Why can’t the proper masks just be made, sold and distributed en masse? That’s what many other places have been doing, including Taiwan, Singapore, and Hong Kong.
Here’s a question that points to an even worse problem: where’s the availability around N95s or KN95s or the FFP2 (European standard) masks that are much better at protecting the wearer?
Even worse, why can I see this at my local supermarket?
That’s right, that’s a bin of KN95s sitting right there, being sold at a price similar to cloth masks on the next shelf over. The cloth masks that don’t have any certification, while these KN95s are registered and approved by the FDA. Why isn’t there a run on them?
It’s all tragic. Just as we made the perfect the enemy of acceptable, we made the stop-gap the enemy of improvement. We get frozen in inaction, and then when we take a step, we get frozen there, too.
Plus, the uncertainty around masks has created a crisis of confidence. When I posted on social media some information about the availability of these KN95s in the local supermarket chain, people were incredulous. Many thought they might be fake—and who can blame them? The country is awash in fake masks. Others couldn’t believe how cheap they were—about a dollar a mask. But why wouldn’t they be at that low price? That’s what they used to cost, and given the pandemic, if we had rolled out the manufacturing properly, that’s what they should have cost, at most.
It’s in the light of all this, I recently wrote an Atlantic article about all this, asking why we weren’t wearing better masks. I ended my article with a mention of “transaction” which says so much about the terrible state of our pandemic response.
One person reached out to say that his fiancée was about to undergo an organ transplant and was expected to do her rehabilitation wearing only cloth masks. A handoff of medical-grade masks was arranged. To an observer, it might have looked like a drug deal: people exiting their cars in a parking lot, searching for someone they clearly had not met before; both looking at the cars around them and their phone until they managed to meet up. Finally, a package was handed over, cash was offered but refused—an agreement was struck to pay it forward with a favor to someone else—and a relieved-looking man took the package back to his car and drove off. But it was much worse than a drug deal, the whole episode proof of a disastrous public-health breakdown in the United States.
Since writing that latest piece, I’ve been inundated with people asking me where to get better masks. Some queries come from scientists and entrepreneurs who have designed or piloted programs manufacturing better masks asking me how to reach the public. Commercial mask-sellers whose products seem to range from snake oil to overpriced cloth masks to items whose quality I can’t evaluate, asking me if I can amplify their product. And so on.
None of this had to be this way.
There was so much terrible messaging about masks early on; I definitely remember stuff going around about how even N95 masks weren’t that effective, regular folks didn’t know how to use them properly and effectively, and anyway, we have to save them all for frontline medical workers. Those ideas clearly took hold!
In Switzerland, where I live, the government first told the media and the public that masks were useless and ineffectual. For more than 3 months after the first lockdown, i.e. until the summer of 2020, that version did not change. It turned out that they unfortunately decided to say that to keep the insufficient numbers of masks available in their storage - at the beginning of the pandemic - for health care workers. Not clear if they were “right” (from a HC system perspective) or if a more transparent policy would have been more effective.