NOTE: The (royal third-person) author is not an epidemiologist, biologist, or medical doctor, and none of this material should be viewed as medical, legal, or parental advice. However, the author does have enough training to understand a logically argued point based on primary (peer-reviewed, please!) sources. As such, if you have one of these to offer in rebuttal, he welcomes it. Vague, emotionally-driven, or bombastic rebuttals may be mocked mercilessly, perhaps even by the author.
The news media have gleefully jumped upon the most extreme anti-mask reactions in their bid for entertainment: the woman who maced a couple that was dining outdoors without a mask, or another woman who threw hot coffee in a man's face for the same reason. The reality, though much more subdued, seems to be in line with the sentiment.
In my own city (where the social distancing was the baseline well before COVID), I have witnessed a newfound sociability, as neighbors berate each other for not wearing masks as they pass each other on the sidewalk, or see bicyclists pass by on the road [a good 15 feet away] without masks. Acquaintances who would otherwise at least respond to a greeting, now painfully look away as I pass them, terrified, perhaps, that eye-contact may lead to a conversation, followed by prolonged proximity, COVID-19 infection, and a certain gruesome death.
We want to believe
There are a number of strong psychological factors that feed into our desire to believe that masks are effective at reducing the spread of COVID:
Simple Mechanism - The underlying mechanism is tantalizingly simple, self-consistent, and comprehensible to the average person: COVID appears to be spread through spit and breathing, which happens from our mouths and noses. Covering our mouths and noses should thus help contain its spread.
Control - COVID is a horrible and unpredictable disease with possible long-term and lingering effects. The experts have had a very hard time modeling its spread and figuring out how to stop it. People desperately need some means of exerting personal control over the disease, and masks provide one simple approach.
Consistent messaging - The importance and effectiveness of mask use is promoted across all venues, from our friends to our news sources and most of our medical doctors.
We have seen this effect before with TSA security theater at our airports, where we let random strangers pat our privates for explosives and confiscate our toothpaste (without any evidence of effectiveness and strong empirical evidence of ineffectiveness!) in order to help us believe that we are protecting ourselves from the horrible and unpredictable scourge of terrorism:
When faced with a horrible unknown threat, we readily grasp any coherent story line that provides a sense of control.
"The Science"™
I am not at all qualified to provide an authoritative opinion about the science of mask usage. However, as a thinking human with some scientific training, I can at least point out that the science on mask effectiveness appears to be equivocal.
Indeed, in a now infamous interview on 60 minutes (March 8), Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases at the NIH and also a lead member of Trump's Coronavirus task force, insisted that:
Right now in the United States, people should not be walking around with masks.
Though he took intense criticism for it, his position appears to be supported by prior work and a recent paper on influenza, published in May by the CDC, whose money line (in the abstract) reads
Although mechanistic studies support the potential effect of hand hygiene or face masks, evidence from 14 randomized controlled trials of these measures did not support a substantial effect on transmission of laboratory-confirmed influenza.
The paper provoked a litany of feedback (as any good result should!), with the two major criticisms described in a subsequent Lancet publication:
This may apply to influenza, but we have no idea that it applies to COVID, and specifically in a pandemic environment;
"... absence of evidence of effectiveness ... should not be equated with evidence of ineffectiveness. "
Both points are reasonable but hardly prove the inapplicability of the original study. Indeed, there are a number of studies that support the possible ineffectiveness of a wide variety of masks against all sorts of disease, especially if not properly fit and utilized (see the citations in the paper by Dr. Colleen Huber [the paper itself does not appear to have been peer-reviewed, and I have no idea how reliable Dr. Huber is as a source]). Indeed, I know of no scientific evidence that long-term mask use is is safe, and there is anecdotal evidence that it may be dangerous in some circumstances.
The CDC does list a number of articles claiming to support for the use of masks, although no elaboration is provided (or obvious). The few mask-related papers in the list appear to be mechanistic in nature - showing that proper use of high-quality masks may reduce the amount of droplet and respiratory transmission, without taking the further step to demonstrate that this is sufficient to actually reduce spread of the virus (e.g., if a few virus particles are sufficient for infection).
Wear the darn mask
So, the science may be murky, but masks make us feel safe. Why not just wear them, in case they help? There are, in fact, several concerns that need to be considered:
Confidence in science - promoting an unsubstantiated position in the name of science risks a loss of confidence in the science, should the position turn out to be wrong (i.e., if it turns out that all that effort we spent wearing masks does not help after all).
Actual risk - By leaving no room for doubt, we could be increasing risk. For example, the CDC lists a number of categories of people who should not wear masks. In a climate of pressure to wear a mask, these people may have to choose between the depression risk of never leaving their home, and the risk of wearing a mask in public when they should not.
False confidence - A person who wears a mask believe that she taking a positive action to protect herself from COVID. This sense of relative safety can easily result in laxity in observing other precautions (such as social distancing or hand washing). If it turns out, for example, that social distancing is more important than mask use for preventing disease spread, then an over emphasis on masks could actually put people in greater danger rather than protecting them.
All this begs for honest and scientifically supported publicity relations for medical decision makers, even in the face of uncertainty and time pressure of a pandemic. Where the science is not yet well understood, it may be safer to admit ignorance (even if we still recommend mask usage) than to insist on a consistent but potentially incorrect message.