This is for my medical colleagues who are struggling to understand what could possibly motivate me to take the irresponsible position against the mandates, or even – in light of our current sociopolitical climate – the recommendation of wearing masks in public. Before you write me off, I deserve a chance to present my argument.
Let’s start with the irrefutable: the more distance and obstructions between an infected person and a non-infected person, the lower the chance of the healthy person getting sick. Period. Not a debate, don’t need a study, don’t need any experts of any kind. One person wearing a mask, less chance of infection. Two people wearing masks, risk reduced further. So why is this continuing to be such a heated issue, and how could any medical provider with a shred of a conscience oppose the use of what may be our only effective weapon against a pandemic of historic proportions?
Because life is complicated, and there is more to it than a virus.
Yes, masks are effective, but think of the scene I have just described as use of a mask in a lab – the in vitro scenario. But the application of any treatment in the real world – in vivo – becomes exponentially more complex. No matter how well things work in a petri dish, there are always side effects. Always. Masks are no exception, and so, we have to balance the benefits with the negatives.
And yes, there are very real negatives.
But first, the benefits. Masks are effective at reducing the spread of infection, but not all masks are created equal, nor are the people wearing them identical. Like many treatments that are promising in early testing, we have had ongoing issues proving the true efficacy in the real world. When specifically designed for and utilized in a particular setting, they have proven to be highly effective, but the effectiveness of random types of masks in an endless variety of settings in a world as varied as the people inhabiting it has proven to be more difficult to validate. This is the difference between what is theoretically possible and what really happens.
From one of the many recent publications:
“Face mask use could result in a large reduction in risk of infection (n=2647; aOR 0·15, 95% CI 0·07 to 0·34, RD −14·3%, −15·9 to −10·7; low certainty), with stronger associations with N95 or similar respirators compared with disposable surgical masks or similar (eg, reusable 12–16-layer cotton masks; pinteraction=0·090; posterior probability >95%, low certainty).”
How can anyone argue with this data? How about the fact that of the 44 comparative studies used to generate it, only one is community based, and that one has a significant selection bias? (It is here).
Also notice the rating of the strength of the statistical analysis (low certainty). Why? Because there are many variables and side effects of societal mandates of public masks that are inseparable.
What we cannot separate out is a placebo effect.
For my non-medical readers, the placebo effect is the somewhat dismissive term given to effects from a therapy that cannot be attributed to the treatment itself, like what might happen if you were given a sugar pill instead of an antibiotic. It is actually a manifestation of the poorly understood mind-body connection that we all have but is frustratingly difficult for physicians to manage. In this case, the placebo effect would include changes in mindset and related behavioral adjustments that a person might adopt while wearing a mask or even while seeing someone else wearing a mask. Some of these are good (reminder to maintain safe social distances in public places; inability to put your finger in your nose). Some of these are bad (reduced ability to meaningfully connect with others; continuous reminder of potentially deadly risk).
I’ll use myself as an example: I have had borderline high blood pressure since medical school. When my father developed vascular dementia – a disease that can be attributed to chronic hypertension – the stress of recognizing that I just might follow his footsteps along a path that I would very much like to avoid, that exacerbated the situation. Which is to say, I kinda freaked out. In an attempt to potentially stave off a loss of cognitive function (that some may say is already in evidence), I decided to start treatment, but with an unconventional regimen: I tried a very small evening dose of a beta blocker, a drug that works by dilating blood vessels and slowing your heart rate. I figured that lowering my blood pressure at night was better than nothing, and I found that it helped me relax and sleep better.
It also made me feel like I was doing something – a placebo effect – reducing the cyclic anxiety that came from worrying about my blood pressure.
And it worked. For a while. One day, as I struggled on a bike ride to get anywhere near my usual performance capabilities (I felt unable to catch my breath), I decided that the cardiac side effects of this drug were just too much. I’d rather take the chance of dementing illness than lose the joy of one of my favorite activities.
(I wonder now if I didn’t have COVID. No, I am not kidding).
Not only is this a demonstration of the placebo effect, it shows a difference in one person’s approach to life vs. another. We are all different, and we all deserve the freedom to navigate this world as we see fit, so long as our choices don’t impact others. Which brings us back to masks, to the side effects, and to these placebo effects that are inevitably tied to their use, and to why something seemingly simple and effective is so much more complicated in vivo than in vitro.
Any issues associated with my blood pressure are all mine. Any risk of doing nothing is for me to endure. If I choose to take medicine, everything involved including the need for a current prescription, the cost, having to regularly go to the pharmacy, plus all of the effects of the drug – physiological and placebo – are what I must balance as pluses and minuses in my life.
I get to choose how I want to live.
Over the past few months, there have been massive changes in the world, and every single person is facing new challenges. As a society, our biggest hurdle appears to be the same one that has tripped us up for eons: a reluctance to allow others the freedom to live as they want to live, to have different opinions, to find strength in different ways, to face challenges on our own terms, to seek and find joy and happiness in widely varied places. This is where the use of a simple face covering becomes inextricably linked to an individual’s freedom to choose how they approach life and all of the adversity that it entails.
At present, this virus is quite literally inescapable. It is possible to avoid being directly affected or infected or symptomatic, but the effects of the pandemic are ubiquitous. Nevertheless, we make different choices: some choose to meet this virus head-on with the goal of minimizing any impact in hopes of establishing a new – albeit different – path forward: a new normal. But some don’t want a new normal, and instead prefer to continue on as before, not oblivious, but accepting the new risks associated with human interaction.
These are both valid, and we have to learn to coexist despite our differences.
For some people, masks provide a benefit, both physiologic and placebo. They provide some protection against a hidden threat and a psychologic feeling of security. The problem here is that this placebo effect with masks is extremely powerful, but it is not always beneficial, and it is not limited to the person wearing the mask.
Doctors have a natural tendency to approach diseases first and foremost through the delivery of healthcare: we focus on treating disease. We also struggle with the real-world issues that confound our scientific treatments. Look at diabetes, which is essentially cured yet remains one of the leading causes of morbidity and mortality. What doctors refer to as “non-compliance” is really just people being people. We are again facing this problem of people being people, and as usual, we can’t take our eyes off the therapy: if everyone would just put on a mask, we would have better outcomes.
But many people – myself included – want to choose a different way to fight this fight, and our viewpoint is not only just as valid, the deleterious side effects are every bit as real as those from a virus that can maim and kill. Statistical data evaluating the benefits of mandates for the public wearing of masks can be shown to move the needle a percent or two. When the numbers of the dead are in the hundreds of thousands, the effects appear dramatic enough to justify the imposition of freedom for the betterment of society. But this analysis is focused on one thing only: outcomes from COVID-19 (and even there the real-world data is weak). When you expand your field of view to include the deleterious socioeconomic impact preferentially affecting those in poverty which – even limiting our headcount to the free world – number in the hundreds of millions, that same 1 or 2% is 1000-fold greater.
The placebo effect of masks is very real. To some, it provides a sense of security, but to others it causes very real harm. It removes an absolutely vital component of life: human connection. It increases paralyzing fear, like that which shaped the unconscionable CMS mandates for nursing homes. These mandates are worse than prison, cutting off “residents” not only from from all outside visitors but also ending communal dining and activities so they are completely isolated, both inside and out. Continued fear is preventing us from doing essential things like educating the next generation. There is no logic in this, no concern at all for anything except statistics related to a single disease. And now – because masks have been made into a political and ethical symbol – those who would choose a different tactic are also feared and shamed.
This is wrong. As a physician, I refuse to condone the shaming and ridicule of people who would choose to live their lives on their own terms, those who are willing to take on substantial personal risk to try to restart the world for the betterment of others, those who value human connection enough to stand strong for our children in the face of a disease for which we have no treatment but cannot be allowed to go on wreaking havoc. There are other ways to fight this fight, more effective ways, more sustainable ways, ways that bring us together instead of driving us apart, ways in which we support each other as we all try to carry on the best we can.
Life is much more complicated than a test tube, and if we don’t include all of the other complexities in our analysis and recognize the differences between in vitro and in vivo, we may end up losing both the battle and the war.