The primary objective of the Smile Free campaign is for all UK mask mandates to be permanently lifted. Here I lay out the case as to why healthy people should never be compelled to cover their faces in everyday public venues. By Dr Gary Sidley.
The Government requirement for healthy people to wear a face covering in a range of indoor community settings, purportedly to reduce the transmission of the SARS-COV-2 virus, has arguably been the most insidious of all the coronavirus restrictions. The summer of 2020 witnessed the phased mandating of masks for all UK citizens, initially on public transport and – shortly afterwards – in shops, supermarkets and schools. Subsequently, there have been periods of widespread compliance, face coverings becoming the most obvious sign that life has changed since the advent of the novel coronavirus.
Perhaps due to a combination of growing opposition to face coverings and a low viral prevalence, the 17th May 2021 witnessed the removal of the requirement for schoolchildren to wear masks in the classroom. On the 19th July 2021 – as part of Step 4 of the Government’s roadmap – the mask mandate was lifted in England, although their wear continued to be ‘recommended’ on public transport and other confined spaces. In contrast, Scotland, Wales and Northern Ireland have persisted with their mask mandates, as has London transport (under the jurisdiction of mayor, Sadiq Khan). (Note: at time of publication, mask mandates have yesterday been re-introduced in England in some settings.)
As for what is to come, public opinion will be a crucial factor in shaping future Government policy in this area and it is hoped that this overview will help people to reach an informed perspective.
Have masks always been recommended during viral pandemics?
Prior to June 2020, public health organisations, and their experts, did not endorse masking healthy people in the community as a means of reducing viral transmission.
In an interview on March 2020, Dr Jenny Harries (England’s Deputy Chief Medical Officer) said that, ‘For the average member of the public’ masks ‘are really not a good idea’ and that ‘people can put themselves at more risk than less’. Professor Jason Leitch (Scotland’s Clinical Director) in April 2020 made the unequivocal statement that, ‘The global evidence is masks in the general population don’t work’. Other senior health officials – including Professor Chris Whitty, Sir Patrick Vallance and Matt Hancock – have made similar comments.
The World Health Organisation (WHO), in their 2019 review of non-drug interventions to manage a pandemic, did not recommend face masks for healthy people. As recently as December 2020, in a WHO document titled ‘Mask use in the context of COVID-19’, it is stated that, ‘There is only limited and inconsistent scientific evidence to support the effectiveness of masking healthy people in the community’. Given these statements it is unclear as to why the WHO changed their advice in the summer of 2020, although according to a Newsnight report it may have been in response to political lobbying.
Is there any evidence that masks reduce viral transmission?
As SARS-COV-2 is a respiratory virus, spread via the breath of one person to another, it is reasonable to expect that a physical barrier covering the nose and mouth would provide a degree of protection. And there is some evidence to support this common-sense assumption.
One research review published in the Lancet concluded that face masks, particularly the medical-quality type, ‘could result in a large reduction in infections’. Several other studies – including this Canadian report – have argued that infection and/or death rates have been significantly lower in countries or regions with mask mandates compared to those without. The authors of another review of both randomised control trials (that provide the most robust type of evidence) and (the less reliable) observational studies came to the opinion that the former underestimated the benefit of masks while the latter overestimated it, their overall conclusion being that face coverings achieved a 6% to 15% reduction in disease transmission.
More recently, a randomised controlled study in Bangladesh reported a small reduction in general levels of community COVID-19 infection when more people wore masks, and extrapolated this finding to claim that – if everybody wore one – there would be a 36% reduction. And researchers at the Indian Institute of Science, after conducting an investigation of the effectiveness of various types of mask in blocking synthetic droplets, suggested that three-layer cloth masks reduce SARS-COV-2 transmission.
However, these studies in support of mask wearing have attracted wide-ranging criticism. The weaknesses highlighted have included: poor methodology; a focus on hospital transmission rather than community transmission; a failure to account for the natural ebb and flow of infection rates; and a reliance on laboratory-based findings rather than those in real-world settings. Also, the studies comparing different geographical areas (masked versus non-masked) are open to the accusation of cherry-picking, as there are at least as many regions where infection rates increased after the introduction of a mask mandate – the UK being one example. To emphasise this point, another study found that states with compulsory-mask regulations in the USA did not realise significantly lower rates of viral transmission than states that did without such mandates.
In addition, the Bangladesh trial was essentially an exploration of the impact of a wider public health and mask promotion campaign, and did not specifically address the potential effectiveness of mask wearing per se. Thus, the marginal reduction in reported COVID-19 infections in the intervention group could plausibly have been the result of changes in other aspects of the participants’ behaviour, such as a greater inclination to stay at home when ill.
Is there any evidence that masks are ineffective in reducing viral transmission?
As previously stated, until recently public health organisations did not recommend masking the healthy in community settings. There were sound reasons for this stance. For example, a review of 14 controlled studies had concluded that masks did not significantly lessen the spread of influenza in the community, protecting neither the wearer nor others. And scientists had argued – despite some recent concerted efforts to censor their views – that cloth face coverings contain perforations that are far too big to act as a viral barrier and therefore ‘offer zero protection’.
In regards to SARS-COV-2 per se, a large randomised control trial (often referred to as the ‘Danish mask study’) found that masks – even the high-quality surgical variety – did not result in a significant reduction in infection risk for the wearer. Furthermore, a recent Spanish study examined over 300 people with COVID-19 and observed no association between risk of transmission and reported mask usage by their contacts. A detailed analysis of all research investigations – including those purported to suggest that masks might achieve some benefits – led to the view that there is ‘little to no evidence’ that cloth masks in the general population are effective in reducing the transmission of respiratory viruses. And another comprehensive analysis of mask efficacy, published in November 2021 by the Cato Institute, concluded that a large volume of low-to-medium quality evidence had ‘largely failed to demonstrate their value in most settings’.
What might be the reasons why masks are ineffective?
Given that SARS-COV-2 is an airborne pathogen, it is a counterintuitive finding that masks do not seem to significantly reduce the risk of transmission. What could be the reason for this surprising result? There are three factors that help explain this unexpected outcome:
- Improper use
Inevitably, in the real world, people often wear masks incorrectly. Ill-fitting devices that are frequently touched, inappropriately stored in coat pockets and glove compartments, and rarely washed (cloth) or appropriately disposed of (plastic), will constitute an infection hazard. There has been recognition of this contamination risk in the scientific literature
2. The minor role of asymptomatic transmission
An often-cited reason for masking healthy people in the community is that it is required to reduce the likelihood that those who are infectious but have no symptoms will unknowingly transmit the virus to others. The Government messaging, based mainly on early small-scale reports from China, typically states that 1-in-3 people infected with SARS-COV-2 are without symptoms. However, more robust research suggests that asymptomatic transmission contributes very little – maybe less than 7% – to the propagation of a pandemic.
3. The virus is spread by aerosols not droplets
Proponents of face coverings frequently argue that they block the spread of virus-carrying droplets in the breath, thereby affording a degree of protection to other people. But there is accumulating evidence that the virus is mainly spread by microscopic aerosols – not the larger droplets – the former being far too small for masks to act as a barrier. Furthermore, one study concluded that cloth face coverings can amplify the spread of infectious particles by acting as a ‘microniser’ transforming large droplets, which would ordinarily fall to the ground close to the person, into smaller, truly airborne ones.
But even if there is a possibility that masks just might help, isn’t it worth wearing one?
Anyone reluctant to wear a face covering risks being challenged by others: ‘It’s only a mask’; ‘It’s no big deal’; ‘If it prevents just one infection, it’s worth it’. These comments are based on the premise that healthy people have nothing to lose from donning a mask when moving around their communities, but they fail to recognise an important truth:
MASKING THE HEALTHY IS NOT A BENIGN INTERVENTION.
What are the potential harms of wearing masks?
The negative consequences of healthy people routinely wearing a mask can be grouped under three headings: physical; social/psychological; and environmental.
Physical harms
In the Western world, the widespread masking of healthy people is a recent phenomenon and, as such, research into the potential harms is in its infancy. There are a lot of unknowns, particularly with regards to the impact of long-term wear on children. Nonetheless, there is accumulating evidence face coverings may be associated with the following physical health risks:
Respiratory illness/pneumonia – with the risk of bacterial infections increasing after only four hours of wear
Reduced heart & lung efficiency
Exposure to contaminants in the textiles
Increased risk of falls in the elderly
Social & psychological harms
Whereas the physical harms of masks, at least in the short term, can often be categorised as mild to moderate irritants, the social and psychological consequences of hiding our faces from other people are profound and ubiquitous. Humans are social animals. We need to interact with others and communicate to sustain our wellbeing. The reactions of the people we meet provide continuous feedback about ourselves and the impact we are having on our fellow citizens. Masks are a major impediment to all these human requirements and, as such, they are de-humanising.
More specifically, the social and psychological harms of face coverings include:
Inhibits emotional expression & social interaction – Face coverings discourage all forms of communication, both verbal and non-verbal. The difficulty in determining the emotional status of someone we meet will inhibit any form of shared pleasantry or human connection. Individuality minimised, identity hidden, the masked population appear broadly the same, as they trudge along in their social vacuums.
Impedes children’s social development – Face-to-face interactions, and positive attachments to adult care givers, are essential for a child’s social development. Masks deny children access to facial expressions, a rich source of information crucial for their psychological maturation and the growth of emotional intelligence.
Maintains elevated levels of fear – Acting as a crude, highly visible reminder that danger is all around, face coverings are fuelling widespread anxiety. Fear is underpinned by a perception of threat and being masked is a blatant indicator that we are all bio-hazards. At the start of the COVID-19 crisis, fear was strategically increased on the recommendation of the Government’s behavioural scientists as a means of promoting compliance with the restrictions. Unfortunately, the resultant inflated fear levels have discouraged people from seeking help with non-COVID illnesses and are likely to have significantly contributed to the tens of thousands of non-COVID excess deaths that have occurred in private homes. It is plausible to suggest that masking is maintaining this elevated level of fear and thereby contributing to this tragic loss of life.
Excludes the hard of hearing – Masks will impede verbal communication, with the hard of hearing – who largely depend on lip reading – being effectively excluded from the conversation. This amounts to around 1-in-6 of the UK population who are prevented from engaging fully in social interaction with their peers.
Promotes mindless compliance – As previously discussed, the scientific evidence that masking the healthy reduces viral transmission is, at best, weak and contradictory. The decision by public health experts to mandate them is likely to have been influenced by the Government’s behavioural scientists in their attempts to enhance the public’s compliance with the range of coronavirus restrictions . We are strongly influenced by what others do, and masks enable easy identification of the rule followers and the rule breakers, thus bringing ‘normative pressure’ to bear on the miscreants to unthinkingly conform. (A recent book, A State of Fear by Laura Dodsworth, lends support to this idea that masks are a tool to promote compliance, a Government advisor informing her that psychologists on the behavioural science subgroup of SAGE liked them because ‘they conveyed a message of solidarity’).
Reduces concentration & impairs learning – Keeping children on task in the classroom is likely to be more difficult when they are masked.
Aggravates existing anxiety problems/ re-traumatises – Wearing a mask will heighten the distress of many people with existing mental health problems and may trigger ‘flashbacks’ for those historically traumatised by physical and/or sexual abuse. Many people already tormented by recurrent panic attacks, involving catastrophic thoughts of imminent death and feelings of breathlessness, will find masks very difficult to tolerate. Regrettably, exercising their legal right to go out without a face covering can attract harassment and victimisation.
Barriers to talking therapies – Facial expressions and other forms of non-verbal communication are vital for the development of a therapeutic relationship, one based on trust, empathy and compassion; in the absence of such a relationship, psychological therapy is rendered ineffective. Although the impact of ‘COVID-safe’ environments on the effectiveness of professional help for people with mental health problems is unknown, masks might be especially problematic.
Enables criminals to evade identification – Unsurprisingly, there have been reports that widespread mask wearing is making it more difficult for police forces to identify crime suspects.
Environmental harms
Numerous discarded face masks litter our streets, as a brief walk in any neighbourhood will confirm. Concern is rising about the environmental damage likely to result from this new major source of pollutants.
Disposable face masks are typically made of non-recyclable plastic. It has been estimated that, each day in the UK, 53 million masks are being sent to landfill waste sites, with many more reaching our rivers and oceans.
Scientists are particularly worried about the dangerous chemicals emitted when masks find their way into our waterways. One study detected a range of potential toxins following emergence in water, including plastic fibres, silicon, poly-ethylene glycol, cadmium, copper and antimony.
Won’t masks help reassure people as we return to normal activities?
It has often been suggested that face coverings can reassure people that they are safe to return to shops, restaurants and other community venues, thereby aiding the economic recovery. The Government endorsed this view in their response to an anti-mask petition when they argued that masks could ‘give people more confidence’ when shopping and therefore encourage them to return to the high street. But as any psychological therapist knows, the assertion that face coverings will reduce people’s anxieties about contracting a virus is absurd.
As already mentioned, masks act as a crude reminder that danger is all around. Furthermore, they constitute what psychologists refer to as a ‘safety behaviour’ that acts to prevent disconfirmation of anxious beliefs; continuing to wear masks will maintain fear as the wearer may attribute their survival to the mask rather than conclude that it is now safe to return to normal activities. To recommend masks as a source of reassurance is akin to insisting people wear a garlic clove around their necks to reduce their fear of vampires.
In summary:
The evidence that masks reduce viral transmission is weak and contradictory, while there is better-quality research to support the conclusion that they do not significantly decrease the risk of respiratory infections in real world settings. Although generally under-investigated, there is accumulating evidence that masking healthy people, particularly for long periods of time, can cause a range of physical harms. More importantly, face coverings are associated with profound social and psychological consequences, with fear maintenance and the stymying of children’s social and emotional development being the most concerning.
Readers will make up their own minds. The Smile Free campaign believes that, in a democratic society, the evidential bar to justify mandating a behaviour should be set very high; the research in support of masks offering protection against SARS-COV-2 infection falls a long way short of this threshold.
If people choose to wear face coverings, so be it, but this should be a personal decision for each individual, not one imposed by Government diktat. All remaining mask mandates should be lifted and this most insidious of all the coronavirus restrictions must never return.
