During the Covid 19 pandemic, I have followed a number of aspects of the science quite closely, specifically: the R number, hydroxychloroquine, vaccination, and masks. In all these instances, even when the science must surely be certain, there was political controversy. Basically, the R number is a measure of how many people one infected person transmits the virus to. One contested issue around R centred on UK government policy, specifically relying so heavily on a metric that could be misleading. Hydroxychloroquine is a malarial prophylactic that was considered as a treatment for coronavirus. While President Trump said that he was taking hydroxychloroquine and advocated giving it to Covid-19 patients before scientific studies were concluded, extraordinarily a paper in the prestigious medical journal the Lancet was withdrawn because its claim that the drug increased the risk of death in Covid-19 patients turned out not to be substantiated by the data. The prospect of a Covid-19 vaccine gave rise to postings on social media identifying fears about potential side-effects, mistrust in political leaders, scientific experts and, tellingly, the pharmaceutical industry.
Each of these instance is worthy of its own analysis, but here I’m going to concentrate on the example of wearing of masks in relation to the Covid-19 pandemic. Even in that simple sentence, nothing is as straight-forward as it seems: there are different types of mask, different social situations in which they might be worn, various groups of people who might wear them, and different reasons for wearing them. There are masks designed for health workers, both N-95 respirator masks and surgical masks; there are industrial dust masks; bandanas in a variety of materials; all manner of homemade cloth masks; face masks and mouth masks. Californians, at least, have been sighted wearing scuba-diving and snorkelling masks. The different social situations in which masks might be worn can be summed up as: in healthcare, in confined spaces, outdoors, and according to proximity to other people. There are vulnerable people and less vulnerable people who might wear masks, and people might choose to do so to protect themselves and/or to protect others.
Up until early June, the World Health Organisation (WHO) strongly advised that a healthy person need only wear a mask (presumably a respirator or surgical mask) if they were taking care of someone infected with Covid-19 (https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public/when-and-how-to-use-masks). If a person had potential Covid-19 symptoms, coughing and sneezing, they too should wear a mask. Otherwise, the WHO stated in one of its online videos: “you do not have to wear masks because there is no evidence that they protect people who are not sick.” So, masks protect health workers but do not protect people who are not sick? Even from a single and should-be singularly authoritative source, the advice appeared instantly contradictory. One possibly hidden issue on the agenda at this point was the wish to reserve a limited global supply of respirator and surgical masks for health workers. In all cases, with all types of masks in all situations, the WHO advised that they would only be effective if used correctly and combined with thorough hand-cleansing, which was of paramount importance.
On the 5th June 2020 the British Medical Association (BMA) reiterated its advice that the public should wear face masks in all areas where social distancing was not possible, including on public transport (https://news.sky.com/story/coronavirus-plans-for-mandatory-face-coverings-dont-go-far-enough-doctors-say-12000768). The UK government made wearing face coverings on public transport compulsory in England from 15th June. As Grant Shapps, the transport secretary, made that announcement, the safe social distance in the UK was prescribed as two metres, though the government was reportedly under pressure from some quarters, particularly business lobbies, to reduce this to 1.5 metres. The WHO says that a distance of 1 metre is safe. While UK government policy followed the BMA’s advice, the chief medical officer for Wales declined to recommend making wearing masks compulsory. Governments in Scotland and Northern Ireland also stuck to their policies on the voluntary use of face mask by the public. Speaking on BBC Radio 4’s influential Today programme, renowned epidemiologist Professor John Edmunds said: “I don’t think mask wearing is particularly effective, but it might help a bit.” In line with the BMA, the Center for Disease Control and Prevention (CDC) in the US recommends the public wear cloth masks where social distancing (6 feet) is not possible, while N-95 respirator and surgical masks should be reserved for healthcare workers (https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/diy-cloth-face-coverings.html). While the US government advises following the CDC’s recommendations, President Donald Trump has described masks as ‘a voluntary thing’ and declined to wear one himself. Culturally in the US, wearing face masks has been linked to appearing unmanly, cowardly, and ‘Asian’, reportedly sparking a backlash against wearing them (https://www.vox.com/2020/5/12/21252476/masks-for-coronavirus-trump-pence-honeywell-covid-19). Stating that it is uncertain whether they have any effect on virus transmission, The Danish Health Authority “does not encourage healthy individuals who go about their daily business to wear mouth or face masks” (https://www.sst.dk/da/corona-eng/faq).
As an aside, I’ll record that a variety of anti-mask laws exist in some US states, and in Denmark it is illegal to wear masks during public assemblies. The irony of potentially being arrested one day for wearing a mask and the next for not doing so was not lost on social media, particularly as Black Lives Matter protests erupted in the US and across the world, including the UK and Denmark, in response to the killing by Minneapolis police of George Floyd. Despite quite widespread impressions to the contrary circulating on my social media, at least, and allegedly among the police themselves, the UK does not have an anti-mask law.
In defence of medical science, like any other sphere of knowledge it must learn and change over time. Indeed, on 5th June the WHO suddenly issued new guidance: people over sixty or with health issues should wear medical-grade masks when they are out of their homes and cannot socially distance, while other people should wear a fabric mask with three-layers. Although there may as yet be no direct evidence that cloth masks are effective in reducing transmission of the Covid-19, they do reduce contamination of air and surfaces that could be media for transmission (1). It may also be a factor in reducing transmission that masks stop you putting your fingers in your mouth or up your nose (https://www.scmp.com/news/china/article/3050539/surgical-masks-protect-more-germs-fingers-viruses-air-experts-say-after). One study conducted on transmission of the SARS virus among healthcare staff in Hong Kong hospitals did conclude that: “Masks seem to be essential for protection” (https://www.thelancet.com/action/showPdf?pii=S0140-6736%2803%2913168-6). The most recent science available to me uses mathematical modelling and concludes that “facemask use by the public, when used in combination with physical distancing or periods of lock-down, may provide an acceptable way of managing the COVID-19 pandemic and re-opening economic activity” (https://royalsocietypublishing.org/doi/10.1098/rspa.2020.0376): an interesting choice of words managing the pandemic and reopening economic activity, not saving lives and protecting each other. Finally, there is a moral argument for deploying the precautionary principle with respect to wearing face masks, not waiting for perfect evidence to make policy (2).
On the 10th of June a spokesperson for Statens Serum Institut, the official body that deals with infectious diseases in Denmark, commented on national radio (DR1) that the WHO was generalising policy for a world that they had to assume was crowded and highly infected with Covid-19. That, he concluded, with respect to wearing masks, was not the case in Denmark. Postings from across the world on social media questioned why measures against Covid-19 were not tailored more to regional and local situations, taking into account population density and infection rate, for instance. Boris Johnson’s government first responded to Covid-19 by deploying the slogan that they would be “Guided by the science”, while numerous critics on social media and elsewhere over the course of the pandemic thought that rather they were ignoring the science (e.g. https://www.wired.co.uk/article/uk-government-boris-johnson-science-advisors). As I write this at the beginning of the second week of June, policy on wearing masks in England is clearly based on the view as expressed by John Edmunds: it might help a bit. There was a row when the UK government decreed that all hospital staff, not only those on the Covid-19 “frontline”, should wear masks from 15th June: NHS Trusts had not been consulted. The chief executive of NHS Providers, Chris Hopson said that healthcare workers believed last-minute decisions are being made because of political rather than public health considerations (https://www.theguardian.com/world/2020/jun/06/face-masks-we-were-not-consulted-nhs-trust-chiefs-complain). International media organisation CGTN studied the minutes of the UK’s New and Emerging Respiratory Threats Advisory Group (Nervtag) and the Scientific Advisory Group England (SAGE) to ascertain what had determined the UK’s policy on masks. CGTN list “10 reasons given for not making general face masks/coverings compulsory”:
- They might add to people's fear and anxiety
- The evidence for mask use by anyone who is not infected "is near nil"
- The general public might use face masks for too long, i.e. even if they became "soggy"
- It could threaten supplies for healthcare workers who need them more
- It might lead to people abandoning social distancing and hand washing
- It might lead to people who are self-isolating leaving their home if they wear a mask
- Inequality concerns – some might not be able to afford or be physically able to buy face masks
- People putting a mask on and off might touch their faces more
- Policing implications if people are wearing face masks
- Could lead to new crimes, such as thefts of face masks
For the most part, I suggest, this list seems an informed and reasonable guide to policy-making. One factor the UK Groups failed to consider, however, was that masks could contribute to a surge in ocean pollution (https://www.theguardian.com/environment/2020/jun/08/more-masks-than-jellyfish-coronavirus-waste-ends-up-in-ocean). To conclude, Table 1 below shows some statistics comparing the records of the US, UK and Denmark on Covid 19. The table does not, I hasten to add, yield any insights into the policy on masks in the three countries. Rather, I think it reflects the US government doing too little and the UK doing too much, too late. (https://europepmc.org/article/pmc/pmc7217796; https://www.forbes.com/sites/marleycoyne/2020/04/30/americans-trust-doctors-and-cdc-not-trump-on-covid-19-survey-reports/#3bde26f6cc6c; https://www.pewresearch.org/fact-tank/2020/05/14/white-evangelicals-among-groups-with-slipping-confidence-in-trumps-handling-of-covid-19/; https://newseu.cgtn.com/news/2020-06-05/Confidence-falls-in-governmental-COVID-19-strategies-in-UK-by-18--R3mLgAVNSM/index.html; https://www.theguardian.com/world/2020/jun/14/lancet-editor-attacks-uk-government-for-catastrophic-handling-of-covid-19-pandemic). By comparison, Denmark would appear to have taken timely and appropriate action Moreover, as I suggested previously, the current politics of Denmark is relatively equanimous, and the citizenry has a relatively high degree of trust in government, certainly vis-à-vis its handling of the pandemic.
Table 1: Infections and death due to Covid 19
Country Cases per 1 million people Deaths per 1 million people
US 5,990 338
UK 4,198 596
Denmark 2,059 101
Source Worldometer 06 June 2020 https://www.worldometers.info/coronavirus/#countries
 From Leonard Cohen’s song “I’m your man”
 N.B. Policy was subject to change on a daily basis.