For Want of a Mask…. (Apologies to Anon) and No, Despite Biden et al, the Language and Guidelines, It Isn’t Over

In the anonymous poem “For Want of a Nail“, a kingdom was lost. Now, I wouldn’t argue that a failure to wear a mask would result in the loss of the country. But I am going to argue that the failure to wear masks inside, even outside in crowds and when speaking at a close distance from someone, is prolonging the Covid-19 pandemic. Because despite all the government lack of action, maskless crowds (even of medical professionals), talk of the pandemic in the past tense to the contrary, we are still in the pandemic.

Wearing a mask is one of the easiest protections against becoming infected with Covid-19. (“Masks are one of the most effective individual public health measures that we can use to protect ourselves and others from COVID-19.”) This is particularly true when everyone in a conversation or situation is wearing a mask. And it is even more true when they are wearing well-fitted masks experts recognize as most effective, such as an N95 mask. Despite this, apart from a few exceptions, governments and most institutions have now decided that it’s up to each individual whether to wear a mask, regardless of circumstances.

And so, we see few masks in any given context, unless they are required. Ontario hospitals still require people to wear a mask — and people do. Grocery stores are no longer subject to mandatory mask protections — and in my experience, while some customers do wear masks, many do not, and in some stores, almost no or no staff wear masks. We see photos of politicians, celebrities and other “famous” people interacting with each other, sometimes with a few people, sometime in a crowd, and no one is wearing a mask. The fact is, mask wearing is pretty much done, except by individuals who worry they will be ridiculed, “judged” or treated as if they are “paranoid” aboutCovid-19.

In this post, I follow the narrative of mask wearing and expectations, mandatory and otherwise, and the language around mask-wearing and the pandemic itself. That narrative has evolved from official warnings against mask wearing to legal requirements to wearing masks to the dropping of those requirements in most contexts, and from criticism of those who wouldn’t wear masks when they were expected to to language more or less making excuses for those who do. Masks are no longer “strongly recommended”; emphasis is now on “choice” and “respect for choice”, whether someone wears a mask or not. (Although the government of Canada recognizes the value of wearing masks, it also emphasizes that doing so or not is a “choice”: “Remember to be kind, understanding and respectful of people’s personal choices.“) One of the most notorious messages appears on posters in the New York MTA (transit authority): it says “yes” to wearing a mask or not and indicates that even if you decide to wear a mask, it doesn’t matter how (the image of a face with a mask right across the middle says “you do you”.

How is this narrative connected to the situation we find ourselves in today, where government has abandoned its duty to promote the health of the population, hospitals are in crisis, Covid-19 levels are high, the expectation is that “everyone will get Covid-19” people are reinfected, we really only have to worry (if at all) about particularly vulnerable people, and “long-Covid” is a medically recognized condition?

In the beginning …

In the earliest days of Covid-19, health officials encouraged us not to wear a mask. Two years ago, Canada’s Chief Public Health Officer of Health advised people who were symptomatic or who had been in close contact with someone with Covid they should wear a mask; otherwise, there were several reasons not to wear a mask. Prioritizing health care workers, the false sense of confidence wearing a mask might provide and the increased face touching that results were three reasons. As the CBC reported on March 31, 2020, “‘Putting a mask on an asymptomatic person is not beneficial, obviously, if you’re not infected,’ Tam said”. Even then, there was criticism of this advice. For example, in the same CBC story, the director of the Institute of Applied Health Research at the University of Birmingham in the U.K., pointed out that asymptomatic people might in fact be infected. And some countries had already imposed mask mandates in a range of circumstances.

(Personal Note: I had no interest in wearing a mask in these early days and was happy to go along with the “official” line. I was careful about being around people, didn’t know anyone who had contracted Covid-19, but did cancel an eye appointment. And this takes us to the next stage.)

How quickly things change…in both directions

Before we knew it, we were in lockdown, beginning in Ontario and elsewhere in March 2020. By May 2020, Theresa Tam was telling us that it was a good idea to wear a mask. By then, a crucial difference between Covid-19 and other viruses had become evident: asymptomatic or pre-symptomatic people might actually be infected. Covid-19 symptoms could take three or so days to emerge after infection. We were already in so-called “lockdowns” and isolation; we already knew that we should keep a distance of six feet from each other. But now masks became a more significant tool in the fight against Covid. We didn’t pay much attention to the kind of mask, though: cloth masks were fine, disposable masks better. Eventually, that morphed into advice to wear KN or N95 masks, definitely not cloth and preferably not just medical masks (although hospitals and other medical facilities sometimes insist this is what you wear when you enter their premises.

(Personal Note: When I started to cover my face, I wore a bandana and then for a long time, a blue 3-ply disposable mask [these were too big for my face]. Now I wear an N95 mask, one of an appropriate size. The only time I don’t wear a mask outside is when I go for a walk or the odd occasion when I’ve eaten or had a coffee outside.)

By July 2020, provinces and territories and cities enacted mandatory mask requirements in indoor public spaces (see, Toronto, for example). These mandates lasted into 2022; in Ontario, with some exceptions, they were eliminated in March of this year.

The removal of the mask mandates occurred at what some would consider the most inopportune time: when people were gathering in crowds at concerts, when almost no one was bothering about maintaining distance in any context. Many people, if not most, live in a delusion of “normality”. And they are encouraged to do so by governments across Canada and elsewhere. Required isolation periods are low, or non-existent. For example, isolation is not mandatory in Nova Scotia: feel free to walk abroad, although not in crowded places, spreading the disease; however, you should wear a mask and fill out a form that provides information about your condition. In Ontario, once they apparently have no more symptoms, kids should return to school and workers to the workplace, preferably wearing a mask for 10 days after symptoms started (“doing the following [wear a mask and avoid high risk settings] can provide extra protection against the spread of COVID-19 and other respiratory viruses circulating in the community“).

Advice from authorities …

The Acting Medical Office of Health for Haldimand-Norfolk Health Unit tweeted at the end of May:

The pandemic is coming to its end.

As a frontline physician, I saw horrendous things: hopelessness and heartlessness wrought both by the virus but also by our, at times, counterproductive restrictions.

Today, I am grateful that these are (almost) all over.

Tweet, May 28, 2022

Last September, almost a year ago, the CBC reported that “Haldimand-Norfolk looks at ways to walk back medical officer of health appointment” because he “used social media to criticize COVID-19 public health measures and say he’d sooner give his kids COVID-19 than a Happy Meal”. In fact, the story explains that members of the health unit (Haldimand-Norfolk council) had mixed views of Strauss.

Strauss may be particularly obvious in his views, but Dr. Kieran Moore, Ontario’s Chief Medical Officer of Health has also diminished the importance of protections against transmission of the virus, emphasizing the level of vaccination in Ontario.

The messaging around mask wearing is best described as corntradictory and weasily. The TCC’s policy is a good example: it states that masks are “mandatory when travelling on the TCC, with some exceptions”, but then goes on to assure people it “will not be enforcing the use of masks”. However, see here where the TTC said it would not have a mask mandate after June 11th, but strongly recommended wearing masks. Similarly, Dr. Kieran Moore, Ontario’s Chief Medical Officer of Health, announced the government will not impose a mask mandate, but “strongly recommended” people wear masks. There’s no need for a mandate, “mainly because Ontarians continue to wear masks despite a mandate. We’re cautious. We’re careful. We’re kinda considerate to each other. And I continue to see masking even outdoors walking on streets in Toronto“. Anyone entering a grocery store knows we can’t count on individuals to decide to wear masks.

Detour …

This has been a quick run through of the changing nature of mask requirements from discouragement to requirements to decide for yourself. However, the picture is, of course, not as simple as even that description. First, it cannot be ignored that the shifting on whether it is a good idea to wear a mask had an effect on the trust level granted public health officials. This ignores the need to adjust advice on the basis of emerging knowledge and experience, but it (although it was not alone in doing so by any means) helped to spawn among a minority — a loud minority– an ongoing resistance not only to wearing masks, but other protections governments imposed. I won’t go into detail about these developments; I have written about some of them previously, as well as other Covid-19 developments [see Slaw posts here, here, here, here, here, here, here, here, here, here and here, among others]. I also think it important to say that governments have made mistakes, even when they are doing what is desirable in my view, ensuring public health protections. Government approaches have required us to suspend judgement and have more faith than we might otherwise accord government action.

(Personal Note: I suspended judgement more than I normally would, but I do believe that Canadian governments, with some exceptions at different points in the pandemic, did try to promote an effective response to the pandemic — at least, until the last months. While I believe changing circumstances should result in changes in approach, in my view, elimination of just about all protections at once (in most contexts) is an abdication of responsibility. I’ve written about this on a previous post on this blog [Racing Towards Normal .. What Are They Thinking?“, February 13, 2022]).)

Changing attitudes and language….

Throughout the mask mandate stage of the pandemic, the onus was on those who refused to wear a mask to explain why. During this period (specifically July 2020), the premier of Ontario, Doug Ford, called anti-mask protesters “absolutely irresponsible” and “reckless”. Some people were simply prepared to give others the benefit of the doubt and assume there was a good reason they couldn’t wear a mask. But in fact, there were very few reasons why someone couldn’t wear a mask.

The real problem lay with those who loudly objected and engaged in protests against mask wearing. Mandatory masks are a denial of freedom, said some, while others claimed they didn’t work or that Covid-19 was a hoax (and therefore objected to all protections). (See several stories: a Vox story from the US from August 2020; a Star article about a Barrie protest in May 2021; and a piece about an organized group camping on Parliament Hill from July to at least September 2020.) The new Conservative Party of Canada leader aligned himself with these scofflaws and opponents of pandemic protections during the so-called “freedom convoy” and has continued to do so; in June, he tabled a bill to prohibit all covid vaccine mandates.

As we adapt to “living with Covid”, as the mantra goes, wearing a mask is a “choice”: no one is stopping you wearing a mask, except perhaps by implicit negative judgements (so far, at least). And we’ ‘re told we should respect the choices of those who wear masks and those who don’t. Have respect for everyone’s choice. When mask mandates were dropped, the language used was that health authorities “strongly recommended” wearing a mask (see, for example, the City of Toronto‘s advice “to wear a mask if you feel it is the right choice for you, based on your level of risk”.). But even then, the emphasis is on protecting the vulnerable, as the City says.

Ontario’s Medical Officer of Health said on June 8, 2022, “While masking requirements are expiring, organizations may implement their own policies. Ontarians should continue to wear a mask if they feel it is right for them, are at high risk for severe illness, recovering from COVID-19, have symptoms of the virus or are a close contact of someone with COVID-19.” This, he said, is because “we have made significant progress in the fight against COVID-19”. Determining whether wearing a mask is “right for them” is a difficult decision for people to make, since the province does not provide satisfactory data on the extent of Covid-19 in the community. As others have said, “we are on our own”. (For a recent story on the new “guidelines”, see here where the CMOH justifies the loose guidelines on “[o]ur collective efforts [that] are helping us move away from a crisis phase to a more sustainable approach to the long-term management of COVID-19”.)

Wearing a mask is often attributed to “fear”, rather than a safe practice that can help protect the wearer and others, vulnerable or not. Only if we test positive for Covid-19 do we know whether we have it. Otherwise, we could have it at almost any time without knowing it and therefore potentially infect another person who, even on the basis that mask-wearing and other protections are to protect persons with applicable disabilities, could infect someone who is vulnerable. Of course, there is no guarantee that masks will prevent infection, but if everyone was wearing one, the spread would be reduced.

One of the most outrageous commentaries about mask wearing appears in a column by Robyn Urback in The Globe and Mail, “Boycotting Canadian Blood Services for ending its mask mandate is illogical“. It illustrates how far we have come from the mask heyday.

On July 25th, Canadian Blood Services (“CBS”) announced it would no longer require donors (or it appears, although it is not clear, employees) to wear masks. In an amazing about face (pun intended), CBC states on its website, “Although no longer required, masks are known to help curb the spread of COVID- 19 and are welcome in our environments and available to anyone who chooses to wear them.”  In the usual contradictory language, it tells donors, “Thank you doing your part to limit the spread of COVID-19 and for respecting each person’s choice to wear a mask or practice physical distancing. ”

It has also eliminated physical distancing, except for “encouraging” people to physically distance. On its website, the CBS explains that its employees and volunteers are vaccinated (meaning?) but that donors do not have to be (although “we strongly encourage donors to be fully vaccinated before entering a collections event”).

CBS explained that “the decision was made in light of the fact that the majority of Canadians are fully vaccinated and that COVID-19 illnesses now tend to be ‘far less severe in most cases.'” (CTV news) However, CBS’s decision resulted in pushback (see here and here, for example). “Fully vaccinated” tends to mean two doses of vaccine, but not necessarily boosters. If people got two doses during the initial efforts to vaccinate the population, they are of little value by now.

CBS is calling for donors, saying they have few blood supplies on hand (a spokeswoman says “collections have been steadily decreasing since July 1” in a Globe and Mail interview. Why? Well, the spokeswoman gives several reasons: “ongoing illness and isolation requirements related to COVID-19, heat-related weather issues and the return of pre-pandemic activities and summer travel that have left many people with less time to donate are all factors contributing to the situation”. Notably, she doesn’t mention the removal of CBC’s mask mandate.

Robin Urback blames those who have announced they will not donate because of the removal of the mask mandate. They have cancelled appointments or have not made appointments when they otherwise would have. This, says Urback, is an example of how “over the course of the pandemic … we’ve collectively lost sight of the forest for the trees”. She thinks CBS’s “calculation” that “it is better to marginally increase the risk of COVID-19 transmission at donor centres (making these centres as risky as grocery stores or movie theatres) than to maintain the status quo of critically low blood supplies” (the low supplies were presumably the reason CBS removed its mask mandate, hoping to bring into the centres those who have declined to give blood because they had to wear a mask).

It is “illogical” to boycott CBS because it has removed its mask mandate, she asserts, since people can still wear a mask if they want to do so:

Some regular donors who were otherwise willing to have a needle stuck in their arms and have about 450 millilitres of blood depleted from their bodies for about 10 minutes are now unwilling to take on the risk of entering a room where the risk of contracting COVID-19 is roughly as high as in a Shoppers Drug Mart.

She places the onus on those who have decided not to donate because of the removal of the mandate: “hopefully they will see that the overall harm caused by denying Canadians of their donations will be more significant that the slightly increased risk of contracting COVID-19”.

There are several problems with Urback’s argument. First, it assumes that other environments are properly without mask mandates. Second, accepting the end of mask mandates in grocery stores, it is different to move around in a grocery store than it is to sit still in a blood collective centre. (I agree cinemas are closer in that people are sitting still, probably next to strangers, but again, why was the mask mandate removed?). Of course, people can wear a mask if they want. At least so far, they are not prohibited, although I wouldn’t be surprised if they were — so as not to embarrass, upset or show disrespect towards those who aren’t wearing masks. Importantly, one way masking is nowhere near as effective as when everyone is wearing masks.

Finally, Urback makes a big error in saying that donors would be giving blood “for about 10 minutes”. As a former blood donor (my reason for no longer giving blood has nothing to do with Covid-19), I can say that it takes far longer than that to donate. First, it may be necessary to line up, even if one has an appointment (perhaps this changed with CBS’s more responsive changes to Covid, but I expect it will returen). It is necessary to confirm personal information and be tested for one’s level of iron. The donor is than required to complete a questionnaire (sitting alone, but in a small area where others have sat probably immediately before) and to have that reviewed by a registered nurse, who also checks the donor’s arms for signs of drug use. Then it’s waiting (usually) for an empty cot. CBC says the donation itself takes 8-10 minutes; however, in my experience, it can easily take a bit longer (if it takes too long, the RN stops the process). The donor is then strongly encouraged to have juice or coffee and a cookie and sit for about 10 or 15 minutes.

Urback’s opinion thus rests on a faulty premise. Her criticism of donors who have decided not to donate because of the removal of the mask mandate is, in my view, appalling and is an example of why the pandemic wears on. Why shouldn’t the onus be on those who won’t give blood because they have to wear a mask to do so; why don’t they show some public interest?

And let’s stop pretending … the pandemic is still taking a toll now and who knows about the future ….

Masks are not a panacea. However, widespread masking can help reduce the spread of the coronavirus and with lower community spread, people can participate in the activities they want to engage in — indoor restaurants, concerts, parties, conferences, attending sports events — with less risk. In-person school will be safer.

I don’t argue masks are the complete answer. They are particularly effective in preventing transmission, though, as vaccinations are not. However, their effectiveness is of course enhanced as part of a suite of protections: proper ventilation, high vaccination rates, including boosters and presumably the new vaccine targeting the Omicron variant, isolating for longer than the five days now required in some jurisdictions, among others. Lower community spread leaves less room for the development of new variants. Keeping vaccinations current at this point will not, it seems, prevent infection, but it will mean the cases are milder for most people. Masks complement the vaccines because they are directed at reducing transmission in the first place.

And reducing infections is important. We know that people can become reinfected and more than once. Vaccines do not provide immunity. Nor do infections. And it seems that reinfections can lead to more serious effects. From being viewed sceptically, “long-Covid” is now recognized as a real condition with a myriad of possible symptoms. And it can result even from mild cases. Thus preventing infection to the extent possible is crucial.

But why worry about masks, the pandemic is over, isn’t it? …

It turns out the bête noir of chief medical officers, the Haldimand-Norfolk chief medical officer, was merely ahead of his time. New Brunswick Minister of Social Development announced that the province was “no longer in the pandemic”; after pushback, a press release revised this to say, “in pandemic lockdown”. But this language is not so far off what we’re seeing more and more often. And possibly the biggest influence of them all, particularly (but I fear no longer only) in the United States, President Biden has declared the pandemic “over” (although we still have “problems with Covid”). His reasoning seems to be based on the fact that no one was wearing a mask at the auto show where he was being interviewed. (More on this below.)

In The Globe and Mail stories on TIFF, which made the most of its in-person festival, used language suggesting the pandemic is more or less over. In a story on the peacock leanings of male stars, the trend towards designers and colourful outfits for men is explained by an editor for a “trend forecaster” as the desire of men “‘[c]oming out of the pandemic'” for self-expression. Another writer, telling us about “TIFF’S coolest canapés”, explains that these bite-size morsels are gaining a “resurgence” now that “COVID paranoia is waning” (although he qualifies that by asking, “it is waning, isn’t it?”). Are we meant to take from that phrasing that being concerned about Covid makes us paranoid?

Given that he writes about movies for The Globe and Mail, perhaps it’s not surprising that Barry Hertz, for example, considers that he is able to make that determination, saying, “Whether we’re out of the woods or not today seems to be a matter of perspective – I’ll place myself firmly in the ‘post-pandemic’ camp – but it is safe to say that TIFF is preparing an 11-day celebration that screams, with mask-free vigour, ‘comeback.'”

In other words, there is nothing objective about whether there is still a pandemic but rather it’s how people view it and where they want to be on the continuum. And while we’re at it, why not laud not wearing masks in crowds?

Those claiming that the pandemic is “over” rarely, if ever, rely on objective scientific evidence. Rather, as one review of the matter states,

“It’s over when people decide that it’s over. … And most people seem to have decided it’s over,” said John Barry, author of “The Great Influenza,” a history of the 1918 Spanish flu.

Most of the experts who spoke with STAT echoed a version of Barry’s remarks: In some respects, the pandemic is over when people stop taking measures to protect themselves, when they stop following advice about how to lower their risk, when they resume pre-pandemic behavior.

STAT, Is the Covid-19 pandemic over? The answer is more art than science

The reality is that the pandemic is not over. Acting as if it is does not make it so. And it leaves us open to even more virulent strains of the coronavirus. (See commentary by experts in this Globe and Mail story.) As André Picard has written, “We are in that cognitively dissonant time now when COVID-19 is still very much a medical threat, but has been deemed to be over, politically and socially” (emphasis added).

The STAT article cites another expert who explains that there are two ways of considering the question: “by looking at what the disease is doing to humans physically and psychologically”. Psychologically, many people are finished with the pandemic, they are fed up with it and they act as if it is over, as if things are “back to normal”. Physically, however, it is more complicated: difficult though it is to measure some of the criteria (the number of reliable positive tests, for example), since governments have abandoned attempts to do so, deaths do rise, schools appear to be rife with Covid cases (although who really knows), “mild” is often a misnomer and long-Covid may be more extensive than any official figures indicate. Furthermore, we do not knows whether there will be more serious variants (it seems there will be if the UK experience is any indication). (See, for example, Canadian Press story here.)

As André Picard, writing in The Globe and Mail about The Lancet Commission’s report on the world’s response to Covid-19 says, “wishful thinking doesn’t end a pandemic. Neither does denial, or no longer caring about who is harmed.” (And if there’s any doubt about how well governments have done over the life of Covid-19, Picard summarizes the report as giving them “a big fat F grade“.}

Conclusion: Back to masks …

So here we are: increasingly language, implicit and explicit, indeed, very direct language, reflects a belief that we are finished with the pandemic. Yet there are still a significant number of cases (probably more than official figures tell us because few records are kept), cases may be mild, but not necessarily so, people are dying in high numbers, Covid lingers or leads to other conditions affecting major organs, we haven’t been through a full cycle of when new variants appear. All this is troublesome, though, and most people seem prepared to get together in large groups without masks, and there is fear among those who still have concerns that statements from someone like the President of the United States (and possibly the World Health Organization, which is giving hints that we’re near the end), may make people even less likely to get vaccinations. “Official” guidance gives people permission to go to work or school while still infected (but without symptoms and wearing masks — but there is no enforcement).

Yet one of the easiest ways to prevent transmission, one just about everyone can satisfy — which then prevents not only mild but serious illness and long-term Covid conditions, never mind death — is to wear a mask when inside. But why would “ordinary people” wear masks when they see doctors at conferences, UN members, presidents and prime ministers, Westminster Abbey guests and on and on, maskless. Why the resistance? (Ah, yes, “freedom, freedom, freedom.) And so, for a want of a mask — who knows who and what we might lose?

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