Beating COVID with masks that work.

What are we doing wrong, and what can we really do to move forward?

If your knee-jerk reaction is, “make everyone wear masks,” then you are headed for disappointment, because what we are doing now is clearly not a solution. Think of the two biggest problems: continued isolation in nursing homes and total disruption of education. If masks are a solution, then why don’t we all put them on and just go back to regular life? Maybe it is because they don’t actually prevent people from getting sick?

No, it’s because people aren’t wearing them, and if everyone would just do this, the virus would go away, and then we could get back to life.

Even if the statement were true (which it’s not), the fact remains that you are not going to get everyone to wear masks, and now that masks are a sociopolitical issue, I am genuinely worried we are headed towards very real violence, and I think we should try to avoid this. So let’s take a few minutes (OK, it might be more than a few) and think it through:

What are we doing wrong, and what can we really do to move forward?

First, let’s recap what we know about this virus, because our knowledge continues to grow. It is clear that the number of infectious virus particles a person is exposed to is incredibly important. It is also clear that there is a wide range of susceptibility, and while some of that is predictable (increasing age being the most important risk factor) we don’t have all of this sorted out. But for sure: a lot of virus will make most people sick, a little virus can make some people sick. One (big) problem: a little virus tends to just sneak around from person to person with the vast majority being asymptomatic, but some unpredictably getting very, very sick.

How is this happening, and how can we stop it?

We know this is a respiratory virus that spreads through the air in two ways: big drops of spit (with virus in them), and tiny aerosolized particles that can hang in the air and float about. So, which is the bigger problem? Though every time someone coughs now, anyone within earshot visibly reacts, it is clear that these big drops – the ones that can only go a few feet at most – are not the problem. I had been discounting the floating virus particles, but this is clearly the main vector. The big droplets don’t go far, and asymptomatic people by definition aren’t coughing, which means the biggest issue is aerosolized virus particles.

By the way, this aerosolized virus goes right through a cloth mask like it’s not even there. Particles that are suspended in the air flow like leaves in a stream wherever the air goes, through the holes in the mask or gaps around the sides. These masks are only effective for larger droplets, and thus don’t do anything for the primary method of transmission, and particularly that from asymptomatic people. Yes, if a sick person is coughing or you are talking face to face with someone a cloth mask will help keep drops of spit from flying out of their mouth and into yours, but you will get infected regardless.  

If someone around you is giving off floating virus, then the farther you are away from them, the less you will get. Think of a sprinkler. Luckily, asymptomatic people give off lower levels of virus, so even being up close for a brief period like passing in the aisle at the grocery store is extremely low risk, but that risk is not zero. Furthermore, keeping your distance is not a perfect solution: in a closed space like a plane or a car or even a room in which the airflow happens to be just so that you are downstream from some virus shedder, you can be infected, and there are well-documented and widely-shared examples. In these settings, the airflow or lack thereof concentrates the floating aerosolized virus, dramatically increasing the inoculum. In all of these scenarios, susceptible people – and we don’t know exactly how to predict that – have to be extra careful, and you cannot rely on a standard mask to protect you.

To sum up: standard masks are not going to prevent the low level, aerosolized spread from asymptomatic people to others, nor will they protect susceptible people from being infected.

This is a real problem, because it means as the world starts to open back up we are going to see an increase in cases and hospitalizations and deaths.

Sound familiar?

But other countries have managed to do this successfully, and they all wore masks, so that’s gotta be the secret.

You are sure that’s causation and not just correlation? No other variables? Are you willing to gamble your life on that logic? How about the lives of your loved ones?

I am not.

This picture is Dr. Fauci boldly caring for Ebola patients, which is flat-out scary and damn impressive, even in a full-on containment suit. But this is not only demonstrates our ability to make effective protective gear, it also shows how completely irrational our current strategy really is.

We should be making the right tools for the job.

Not all masks are created equal, and for many years we have had masks that are proven effective to prevent the wearer from being infected by tiny, aerosolized pathogens. The difference in performance of N95 masks in terms of filtration and protection are orders of magnitude beyond cloth masks, especially when there is literally zero standardization or performance requirements beyond the casual observer’s ability to see your face.  Literally: all they are required to do is cover your face. When viral load at exposure is a critical factor and when we are talking very small aerosolized particles that can hang in the air and easily flow through or around these visual barriers, choosing them as a primary method of defense against a pandemic that has brought the world to its knees is laughable. Except none of this is remotely funny.

Here is the FDA’s documentation on masks. You should read it. Note that the first line states:

The Centers for Disease Control and Prevention (CDC) does not recommend that the general public wear N95 respirators to protect themselves from respiratory diseases, including coronavirus (COVID-19).

Instead, regular people are supposed to wear, “simple cloth face coverings.”            


N95 masks “are critical supplies that must continue to be reserved for health care workers and other medical first responders, as recommended by current CDC guidance.”

So let me get this straight: we are already testing vaccines – and spending billions upon billions of dollars in this arena – but we can’t remedy a shortage of masks that are proven effective at protecting vulnerable people from getting sick? Come again? We funnel all of our resources, efforts, and money into something that is unlikely to be as good as the one for influenza and is unlikely to be able to protect the most vulnerable (elderly) and is likely to be opposed by many people due to a lack of testing, all so that we might hope to achieve some level of herd immunity, because it will reduce but hardly eliminate the infection and hospitalization and death of susceptible people? And all the while we are virtually ignoring the proven method of directly protecting anyone that really needs to be protected?

And anyone pointing out the flaws in this logic is irresponsible?

Why are we not actively working to make more comfortable, easier to use, longer lasting, purpose-built, tested and certified masks that can actually protect a person without any adverse side effects either to the individual or society at large?  Why are we not distributing these to teachers so that they can simply go back to work? To our elderly, so they can be protected when around healthcare workers that have to see multiple people or when being visited by their families, so they don’t suffer and die in social isolation?

Meanwhile, our guidance for how to actually carry out a sustainable existence, one that includes the ability to interact with other people – an essential component of life for the majority of people – can be summed up in one  word: STOP. That’s not guidance, that’s panic.

We need to be applying those resources, efforts, and money to critical areas of our lives so that we can restart them safely, intelligently, and now. Things like airflow. Hospital air management includes careful consideration of the flow of air into and out of various rooms to prevent things like cross contamination, and to assure adequate turnover. We never had to do that to schools in the past, but perhaps we should be hard at work fixing these things, especially when we know what we need to do and have the expertise. Yes, this would cost money, but at least the money would do something effective, as opposed to the incredible costs of shutting everything down to clean surfaces which will do exactly nothing.

Some things will have to be remote now, so why are we not mandating internet and cell phone connectivity for all? In what world is it fair that public schools have a major remote component when there a literally millions of kids who will be unable to participate? In America, educational neglect is a crime.

But protecting people effectively – and we can do that right now, whether you are a doctor or a nurse or a first-responder or a teacher or a cancer patient or elderly – that trumps everything else.   

What we are doing wrong is trying to mandate a plan that is never going to work for two irrefutable reasons: it is not a logical plan based on current scientific knowledge (cloth masks will do nothing to prevent the spread of the virus), and it is not a logical plan based on societal realities (you cannot force people in a free society to do anything without massive repercussions).

Everything changes if we have an effective way to protect anyone from this disease. If a person is adequately protected even when exposed to potential dangerous levels of virus, then the behavior of others (which you will never control) is no longer a factor. Furthermore, we remove the social division and conflict that invariable accompanies mandates of any kind.  We are at each other’s throats because of a misconception that one person’s actions are impacting the health and wellbeing of others when we have a proven method of prevention of spread and we are failing to administer that method.

What we could do about it is start distributing effective protection to those who need or want it along with proper education on how to use it. We could be taking some of those billions and incentivizing our innovative to improve on the current offerings and tailor them to this specific threat, as well as to increase production so that there is adequate supply. No one loses with this plan, which would allow healthcare providers to expand the use of better PPE in broader situations and in greater comfort. A teacher who is worried about COVID – or any other respiratory disease like influenza that is still going to kill thirty thousand people in a good year including a higher percentage of young people – could be effectively protected. Immunocompromised such as cancer patients would have a much better way to safely mitigate risk, as would their loved ones who need to be just a vigilant.

And we could focus our efforts on collaborative solutions that effectively protect others, instead of ineffective mandates that inevitably divide us.

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