The Great Mask Debate is limping towards closure. While there is no single conclusive piece of evidence, the best research points towards there being little or no general benefit from the mass use of masks in the community. It is even doubtful whether there is much value from requiring masks in health care settings or care homes. My mask does not protect you and your mask does not protect me.
Mask advocates have repeatedly doubled down on their case. While conceding that cloth masks are unlikely to be effective, they urged us to wear N95/FP2 masks, intended for industrial purposes. These have not been shown to make much, if any, improvement. This is not surprising because no health and safety agency has ever thought they protect workers exposed to viruses.
More recently, advocates have claimed that these masks offer special protection to people whose medical conditions make them particularly vulnerable to infections. They should continue to wear masks, and have others wear masks around them. However, as the UK Health Security Agency found this week, no studies have been done that would support this recommendation. Why would masks block transmission in this group when they do not seem to do so in the general population?
The lack of good-quality evidence on the use of masks is a major policy failure. From the early summer of 2020, some of us were noting that previous research did not support the mass use of masks to reduce transmission. Senior Department of Health and Social Care (DHSC) medics clearly agreed. Both Deputy Chief Medical Officers, Jonathan Van Tam and Jenny Harries, expressed early reservations in public and the leaked WhatsApp messages linked to the former health minister, Matt Hancock, show that the Chief Medical Officer, Chris Whitty, shared that view in private. After leaving DHSC, in a BBC radio interview, Van Tam repeated his scepticism. These uncertainties did not, however, translate into research contracts.
This failure matters for three main reasons.
First, for those who genuinely do not benefit from vaccination. They are a very small group – most people originally thought to be vulnerable get adequate protection through vaccination although they may need an extra shot and periodic boosters. The suggestion that masks are a substitute is a cruel deception practiced in the name of care. This group have always had a heightened risk from infections and been advised to manage their everyday lives accordingly. Endemic Covid does not demand different behaviour from, say, influenza or RSV.
Second, for trust in science. The pandemic revealed a nasty streak of authoritarianism in some medical circles. Every commitment made by leading medics and scientists in the last thirty years to public dialogue, engagement and partnership was binned in favour of a false certainty and a simplistic read-off from science to policy. Public health leaders used to see their role as public educators, acknowledging uncertainties. The Chief Medical Officer who dealt with the early years of the HIV/AIDS pandemic refused to go along with fear-based messaging and legal controls on those who tested positive. ‘Just do as I say’ is not a good way to build trust, let alone being nudged by subliminal pressures to comply rather than question.
Protection from infection is not the only possible goal of public policy. Covid-related deaths are not the only deaths that matter. Take the criticism of Eat Out to Help Out, a UK scheme to subsidise restaurant dining in the summer of 2020. It may have led to more Covid infections but it also rescued national morale from the pandemic of fear and sustained an important sector of the economy. Politicians are entitled to make such choices without being assailed for ignoring ‘the science’.
Third, for democracy itself. It is a fundamental principle that democratic states use their power with restraint and with clear justification. Democracies create the largest possible space for citizens to do their own thing, provided they do not harm others. Where imbalances of knowledge and power distort that space, states may intervene to level the playing field and prevent harms. But the burden is always on states to show that those interventions are effective.
Much Covid public policy conspicuously failed to do this because social interventions were not subjected to the same rigorous tests as medical ones. Historians knew that masks had not worked in previous pandemics. Sociologists and anthropologists knew that mask wearing in South East Asia was a complex and context-specific practice. It was not universal within the region let alone a model for the rest of humanity. Lawyers knew that mask mandates were unlikely to have the intended effects because laws are not simple commands that compel obedience. Psychologists knew that masks were likely to have an adverse impact on child development, on people with sensory disorders or neurodiversity, and people with previous traumas.
The lack of high-quality research on masks stands for the wider policy failures of states that excessively privileged expertise from the medical and natural sciences without recognizing that its impact always depends on its translation into actions by ordinary citizens.
A shorter version of this piece was published in the Sunday Telegraph on April 16, 2023