Thanks for writing this. It reminds me not to drink the Kool Aid.
One topic that you don't point out is that before the authorities mandate a health intervention, the burden is on them to prove the intervention has a net benefit. As you have laid out here, at best all one can say is that there is no evidence that masks affect community transmission in a material way. They have not run reliable studies that demonstrate that masks work. I'm done listening to them.
Personally, I don't think masks make a material difference. I live in LA one of the most masked places on earth. Right next to us is Orange County. They have no mask mandates. Look at the graphs of cases, hospitalizations, deaths, etc. for LA County and Orange County and you will see the charts are virtually indistinguishable.
The world was going to end because a court ruled that the CDC didn't have the authority to mandate masks on airplanes. Masks on airplanes ended -- and nothing happened.
You are right in some sense, but there is a balance in the strength of proof when considering potential costs and benefits. Many would argue given the enormity of the risks initially associated with Covid-19, it was worth the harms in the short term (which for most individuals are very modest) to deploy masks even given the uncertain level of benefit. I could possibly be convinced of that, but the problem is no further evidence was offered and the benefits rapidly diminished alongside the diminishing risk.
For whatever its worth, I definitely saw an uptick in travel related cases clinically once mask mandates were dropped. Certainly some possible confounders there. Otherwise agree.
Thanks for such a balanced and nuanced article Alasdair. As ever, you cut through the noise. I cannot wear a mask, I'm autistic, and one thing struck me from the start of the mandates: if masks were indeed so VITAL and worked SO WELL nobody would have been exempt from wearing them here in the UK.....and it still amazes me that nobody ever picks up on this. I suffered verbal and psychological abuse for 2 years and got chased across retail outlets because of the hatred and division the mandates caused. I hope we never see such a damaging public health policy return.
Thank you for your comment, and I am so sorry to hear you had such a difficult time. There are huge issues when public health measures become so divisive, and for such a visible (and sadly politically affiliated) measure such as masks it is even worse.
Hopefully this is something we can learn from for the future.
What is also little known is that the UK legislation was written so that anyone could lawfully declare an exemption without having to reveal their "reasonable excuse." There were also settings excluded from the law such as healthcare and education. The system relied on fearful, vindictive, human herds and very many people will not learn. History shows us that.
That may well be true, but we can endeavour to give our institutions the best possible chance of remembering. A lot of it returns to making public health a legally enforceable matter, rather than guidance. I have written about it previously.
I appear to be one of the few people that are largely indifferent to mask. I guess that makes me a centrist. It is, however, very frustrating that there is so little good data about when, where and how well masks work in the community. For example, I would like to know what the actually impact from wearing a N-95 on public transit or similar situation is on my overall chances of catching a respiratory infection. My sense it very little, but if we knew then I could actually make an informed cost-benefit analysis based on my own preferences.
For immune susceptible people, every exposure renders risk. Even if an N95 reduces risk of infection, by, say, 80% on a given exposure, basic laws of probability guarantee that the benefit of wearing it diminishes markedly the more a person is exposed. When immunity isn't a player, a person exposed once would face an 80% lower risk if they wore a respirator. But if they are exposed twice, their risk benefit reduces to 65%. At 10 exposures, there benefit reduces to 10.7%. At 20 exposures, the benefit of wearing reduces to 1.2%, now basically in the noise. At that point, their number of infections won't be statistically different from those of a person who never masked at all. This, in my opinion, is the main reason why it is so difficult to show a benefit of wearing masks in a population that frequently mingles in the presence of a highly transmissible virus.
Only when people take action to massively reduce their exposure levels can they gain substantial benefit. e.g., a person who mostly isolates at home and masks during the unusual times they go out can benefit substantially. A person who works at a school, university, airport McDonalds, or who frequently rides public transport can't likely benefit.
I think it’s more than reasonable to have mandates when an unknown, never-experienced-before global pandemic situation is happening.
We now know that at least 1.1 million people died from COVID so far and so many deal with long COVID complications. Think of ALL those who’ve LOST all those who died and their utter grief and even loss of wage earners
I honestly can think of upsets wayyyy more horrible than wearing a mask. I’m grateful we are not in a war where bombs are falling, rampant violence- etc …I hope masks are our worst.
That said, it’s plain mean to harass or become violent with others who don’t wear them. People are anxious STILL with PTSD like feelings from how the world changed on a dime. Many people feel these things nowadays, those who wore masks and those who don’t, won’t, or cannot.
Perspective people- that’s a rare commodity; more so than great clinical trials for masks.
Oh my god Mr (or is it Dr) Munro. You show the general public (i.e. Twitter) a normal distribution of data to do with mask wearing? You have a lot more faith in the public than I do especially after what I’ve seen in the past 3 years. I think it’s fair to say that in the general population masks are STATISTICALLY ineffective as you have eluded to in your post. In controlled settings with proper instruction and well manufactured product, most certainly they must have some minimal effect. But that’s a far cry from what I’m used to seeing. Rolled up turtle necks are not good masks they might land u a date but most likely COVID as well. Don’t forget at the height of the pandemic they used to have arrows in grocery stores designating the aisles one way only and I’ve seen individuals break out into fist fight over it for not complying ( with the traffic signs that is ). So in short your post shows you know your stuff you can analyze with scientific logic. As you claim the the study doesn’t say they work but u can’t deduce from it that they don’t work. As I have always maintained: you cannot apply the scientific method very well to medical science.
Two conceptual questions about masks, respirators, and other exposure measures:
1) Would reducing exposure reduce infections, or just delay them for a brief period of time?
Would we simply delay time to achieve minimum infective dose by a few minutes?
2) Would reducing exposure to an unwanted virus in community settings also reduce exposure to other viruses that may inhibit the unwanted virus? Would reduced cross immunity cancel out benefits from reduced exposure to the unwanted virus?
One study suggests infection with one of two common coronaviruses was associated with reduced risk of Covid infection. One study suggests that for older adults, living with young children was associated with reduced serious illness from Covid.
In the Cochrane Review, some underlying RCTs had low compliance; others high compliance.
Cochrane's Review did a separate sub analysis of RCTS on N95 Respirators vs Surgical masks in medical settings. Those RCTs generally had higher adherence to protocol.
In your controlled setting example where masks might have an effect you didn't mention the important aspect of disposal. I'm sure it's always done correctly in the setting you describe but it's another factor that is rarely addressed when discussing community mask wearing - the length of wearing, not to reuse and to adequately dispose without contamination. I was one of the people who actually watched one of the WHO how to wear a mask videos that they produced when they did their about turn on wearing a mask. I knew, at that moment, that not only was no one being advised in the correct way, as part of central government announcements, but that, even if they were, it would be impossible for whole communities to adopt the strategies that might make wearing a mask to stop viral infection actually work. Meanwhile we seem to have forgotten that the idea of the mask wearing was always supposed to be to stop the infected person being so much of a spreader which has always made me not particularly surprised that the information about whether masks 'work' had been a terrible mess. Even what they're supposed to work at doing is muddled. PS always remember to explain clearly what community effects means versus individual behaviour and consequence. PPS is anyone going to ever look at the other analysis in the Cochrane review about other forms of physical intervention?
I'm curious. are you a PPE expert? Every Industrial Hygenist that I've seen has stated that masking doesn't work and is not recommended. Stephen Petty, an expert witness in PPE has testified as such. https://www.youtube.com/watch?v=J3dnkbKoj4A&t=2s. Why is it you are talking about this like it is not well understood by subject matter experts that masking is ineffective. The studies have been out for years. The data is clear. If the mask doesn't seal, amy minor gap renders the filtering properties of the mask useless as the air just goes around the filter. If you can't filter down to N95 levels, then the mask won't filter SARS2 with to any reasonably safe level. Masking has NEVER been recommended for children. Subject matter experts already know this and have known this for years. There is no way to get around the physical limitations of masks or the fact that in general, people will not were them correctly. You are also just totatlly ignoring the very real negatives to masking. If you are serious about this subject, why no mention of any of the negatives from wearing masks like hypercampia, the forced plumes that keep the virus aloft for longer or the very real possibility of reinfection from touching the mask proper or mishandling the mask and just putting it in a pocket.
I think through vaccination and infection. Everyone who can become immune has reached reasonable immunity. Immunity does not prevent completely getting infected, but it obviously reduces the likelihood of disabling or fatal outcome. Unfortunately, many people will toward the end of their life, whether it be from old age or from immunosuppressive Younger age, onset, diseases arrive at a place of no longer being adequately immune to avoid bad outcomes. It is these people that need to be put into a randomized trial of intensive Covid prevention versus regular background guidance. The intensive arm of the study should include education on and 95 mask use, and then monitor adherence to mask use in both groups. Mortality, mortality, due to Covid, hospitalization due to Covid, should be the outcomes to measure.
Thanks for writing this. It reminds me not to drink the Kool Aid.
One topic that you don't point out is that before the authorities mandate a health intervention, the burden is on them to prove the intervention has a net benefit. As you have laid out here, at best all one can say is that there is no evidence that masks affect community transmission in a material way. They have not run reliable studies that demonstrate that masks work. I'm done listening to them.
Personally, I don't think masks make a material difference. I live in LA one of the most masked places on earth. Right next to us is Orange County. They have no mask mandates. Look at the graphs of cases, hospitalizations, deaths, etc. for LA County and Orange County and you will see the charts are virtually indistinguishable.
The world was going to end because a court ruled that the CDC didn't have the authority to mandate masks on airplanes. Masks on airplanes ended -- and nothing happened.
You are right in some sense, but there is a balance in the strength of proof when considering potential costs and benefits. Many would argue given the enormity of the risks initially associated with Covid-19, it was worth the harms in the short term (which for most individuals are very modest) to deploy masks even given the uncertain level of benefit. I could possibly be convinced of that, but the problem is no further evidence was offered and the benefits rapidly diminished alongside the diminishing risk.
For whatever its worth, I definitely saw an uptick in travel related cases clinically once mask mandates were dropped. Certainly some possible confounders there. Otherwise agree.
Thanks for such a balanced and nuanced article Alasdair. As ever, you cut through the noise. I cannot wear a mask, I'm autistic, and one thing struck me from the start of the mandates: if masks were indeed so VITAL and worked SO WELL nobody would have been exempt from wearing them here in the UK.....and it still amazes me that nobody ever picks up on this. I suffered verbal and psychological abuse for 2 years and got chased across retail outlets because of the hatred and division the mandates caused. I hope we never see such a damaging public health policy return.
Thank you for your comment, and I am so sorry to hear you had such a difficult time. There are huge issues when public health measures become so divisive, and for such a visible (and sadly politically affiliated) measure such as masks it is even worse.
Hopefully this is something we can learn from for the future.
Thanks, let's hope so 🙏
What is also little known is that the UK legislation was written so that anyone could lawfully declare an exemption without having to reveal their "reasonable excuse." There were also settings excluded from the law such as healthcare and education. The system relied on fearful, vindictive, human herds and very many people will not learn. History shows us that.
That may well be true, but we can endeavour to give our institutions the best possible chance of remembering. A lot of it returns to making public health a legally enforceable matter, rather than guidance. I have written about it previously.
https://alasdairmunro.substack.com/p/covid-restrictions-how-we-lost-our
Oh, that suggests to me full-on mask, quarantine and vaccine totalitarianism. Who would provide The Sword and Shield of Public Health?
I haven't gone to the link, but I'm scared to now. Have I misinterpreted your second sentence?
I appear to be one of the few people that are largely indifferent to mask. I guess that makes me a centrist. It is, however, very frustrating that there is so little good data about when, where and how well masks work in the community. For example, I would like to know what the actually impact from wearing a N-95 on public transit or similar situation is on my overall chances of catching a respiratory infection. My sense it very little, but if we knew then I could actually make an informed cost-benefit analysis based on my own preferences.
For immune susceptible people, every exposure renders risk. Even if an N95 reduces risk of infection, by, say, 80% on a given exposure, basic laws of probability guarantee that the benefit of wearing it diminishes markedly the more a person is exposed. When immunity isn't a player, a person exposed once would face an 80% lower risk if they wore a respirator. But if they are exposed twice, their risk benefit reduces to 65%. At 10 exposures, there benefit reduces to 10.7%. At 20 exposures, the benefit of wearing reduces to 1.2%, now basically in the noise. At that point, their number of infections won't be statistically different from those of a person who never masked at all. This, in my opinion, is the main reason why it is so difficult to show a benefit of wearing masks in a population that frequently mingles in the presence of a highly transmissible virus.
Only when people take action to massively reduce their exposure levels can they gain substantial benefit. e.g., a person who mostly isolates at home and masks during the unusual times they go out can benefit substantially. A person who works at a school, university, airport McDonalds, or who frequently rides public transport can't likely benefit.
I think it’s more than reasonable to have mandates when an unknown, never-experienced-before global pandemic situation is happening.
We now know that at least 1.1 million people died from COVID so far and so many deal with long COVID complications. Think of ALL those who’ve LOST all those who died and their utter grief and even loss of wage earners
I honestly can think of upsets wayyyy more horrible than wearing a mask. I’m grateful we are not in a war where bombs are falling, rampant violence- etc …I hope masks are our worst.
That said, it’s plain mean to harass or become violent with others who don’t wear them. People are anxious STILL with PTSD like feelings from how the world changed on a dime. Many people feel these things nowadays, those who wore masks and those who don’t, won’t, or cannot.
Perspective people- that’s a rare commodity; more so than great clinical trials for masks.
Oh my god Mr (or is it Dr) Munro. You show the general public (i.e. Twitter) a normal distribution of data to do with mask wearing? You have a lot more faith in the public than I do especially after what I’ve seen in the past 3 years. I think it’s fair to say that in the general population masks are STATISTICALLY ineffective as you have eluded to in your post. In controlled settings with proper instruction and well manufactured product, most certainly they must have some minimal effect. But that’s a far cry from what I’m used to seeing. Rolled up turtle necks are not good masks they might land u a date but most likely COVID as well. Don’t forget at the height of the pandemic they used to have arrows in grocery stores designating the aisles one way only and I’ve seen individuals break out into fist fight over it for not complying ( with the traffic signs that is ). So in short your post shows you know your stuff you can analyze with scientific logic. As you claim the the study doesn’t say they work but u can’t deduce from it that they don’t work. As I have always maintained: you cannot apply the scientific method very well to medical science.
Two conceptual questions about masks, respirators, and other exposure measures:
1) Would reducing exposure reduce infections, or just delay them for a brief period of time?
Would we simply delay time to achieve minimum infective dose by a few minutes?
2) Would reducing exposure to an unwanted virus in community settings also reduce exposure to other viruses that may inhibit the unwanted virus? Would reduced cross immunity cancel out benefits from reduced exposure to the unwanted virus?
One study suggests infection with one of two common coronaviruses was associated with reduced risk of Covid infection. One study suggests that for older adults, living with young children was associated with reduced serious illness from Covid.
Hers is a news article summarizing the studies:
https://www.cnbc.com/2022/12/16/interacting-with-small-kids-may-lower-risk-of-severe-covid-outcomes.html
In the Cochrane Review, some underlying RCTs had low compliance; others high compliance.
Cochrane's Review did a separate sub analysis of RCTS on N95 Respirators vs Surgical masks in medical settings. Those RCTs generally had higher adherence to protocol.
In your controlled setting example where masks might have an effect you didn't mention the important aspect of disposal. I'm sure it's always done correctly in the setting you describe but it's another factor that is rarely addressed when discussing community mask wearing - the length of wearing, not to reuse and to adequately dispose without contamination. I was one of the people who actually watched one of the WHO how to wear a mask videos that they produced when they did their about turn on wearing a mask. I knew, at that moment, that not only was no one being advised in the correct way, as part of central government announcements, but that, even if they were, it would be impossible for whole communities to adopt the strategies that might make wearing a mask to stop viral infection actually work. Meanwhile we seem to have forgotten that the idea of the mask wearing was always supposed to be to stop the infected person being so much of a spreader which has always made me not particularly surprised that the information about whether masks 'work' had been a terrible mess. Even what they're supposed to work at doing is muddled. PS always remember to explain clearly what community effects means versus individual behaviour and consequence. PPS is anyone going to ever look at the other analysis in the Cochrane review about other forms of physical intervention?
I'm curious. are you a PPE expert? Every Industrial Hygenist that I've seen has stated that masking doesn't work and is not recommended. Stephen Petty, an expert witness in PPE has testified as such. https://www.youtube.com/watch?v=J3dnkbKoj4A&t=2s. Why is it you are talking about this like it is not well understood by subject matter experts that masking is ineffective. The studies have been out for years. The data is clear. If the mask doesn't seal, amy minor gap renders the filtering properties of the mask useless as the air just goes around the filter. If you can't filter down to N95 levels, then the mask won't filter SARS2 with to any reasonably safe level. Masking has NEVER been recommended for children. Subject matter experts already know this and have known this for years. There is no way to get around the physical limitations of masks or the fact that in general, people will not were them correctly. You are also just totatlly ignoring the very real negatives to masking. If you are serious about this subject, why no mention of any of the negatives from wearing masks like hypercampia, the forced plumes that keep the virus aloft for longer or the very real possibility of reinfection from touching the mask proper or mishandling the mask and just putting it in a pocket.
I think through vaccination and infection. Everyone who can become immune has reached reasonable immunity. Immunity does not prevent completely getting infected, but it obviously reduces the likelihood of disabling or fatal outcome. Unfortunately, many people will toward the end of their life, whether it be from old age or from immunosuppressive Younger age, onset, diseases arrive at a place of no longer being adequately immune to avoid bad outcomes. It is these people that need to be put into a randomized trial of intensive Covid prevention versus regular background guidance. The intensive arm of the study should include education on and 95 mask use, and then monitor adherence to mask use in both groups. Mortality, mortality, due to Covid, hospitalization due to Covid, should be the outcomes to measure.