Mask deniers and the Swiss Cheese model
It’s inevitable that there will be a backlash to any concepts that have widespread societal impact. It doesn’t matter what realm we’re talking about, there will always be deniers.
Deniers can focus their efforts on something with violent undertones (like Holocaust deniers) or something totally harmless that’s just odd (like flat earthers).
Deniers exist in all kinds of areas in medicine. I think about the statin deniers, the people who believe vaccines cause Autism, or the current flavor of the month: Mask deniers.
Who are the mask deniers?
You can place the rationale for mask denial into a handful of different buckets:
People who don’t believe masks protect from COVID
People who don’t believe COVID is dangerous, so a mask is unnecessary even if it may prevent COVID transmission
People who think masks make you sick because they impair your ability to breathe
People who just find masks uncomfortable and believe the discomfort from the mask is worse than any benefit
Contrarians for the sake of being contrary
Most people don’t choose not to wear a mask because they are assholes. There’s generally some type of motivated reasoning behind it, just like there is for the majority of counter-productive human behaviors.
You can also subdivide mask wearers a different way:
Folks who wear masks every time they are out of their home, even if they are outdoors and physically isolated from others
Folks who wear masks in high risk situations, like indoors with others around or in crowds
Folks who never wear masks
The public health goal isn’t to maximize the number of human hours spent mask wearing
We all want to slow the pandemic and get back to our normal lives. I fear that turning mask wearing into a type of virtue signaling is going to make the mask backlash worse.
There was an interesting thread on Twitter from a mathematician named Wes Pegden that I read discussing the optimal method of mask advocacy from a utilitarian public health perspective.
He makes the point that getting people from Group 3 (never wearing masks) to Group 2 (wearing masks in high risk situations) is much more important than getting people from Group 2 into Group 1.
Turning a never-masker into an occasional-masker is both the more difficult and more important task when we think about public health.
COVID superspreaders and superspreading events are driving this pandemic. Reducing the number of superspreading events cannot be overemphasized in importance.
Presenting a case that we should all wear masks all the time and creating an environment where shaming mask-less people is the norm may be counterproductive with regards to turning the tide of our worsening.
A Swiss Cheese model is a good intellectual framework
The Swiss Cheese model of accident causation can be tweaked for application to a pandemic.
In a model like this, every potential intervention or step has some holes in it - i.e. no intervention is perfect - but when we line up a number of different strategies, we end up reducing spread:
For something like a pandemic, which has the potential to be a society-destroying catastrophe, making an argument for mask wearing through a framework like this may help to bring mask deniers from Group 3 to Group 2.
Masks aren’t perfect, and I think we all agree that they’re not fun to wear. But they’re one layer of our protection. And they are also most effectively deployed in high risk sitautions.
A doctor doesn’t need to wear gloves when talking on the phone with a patient, but does need to wear them when stitching up a wound.
We should think about masks similarly.
You don’t need to wear a mask when you’re walking your dog or going for a jog in the park. But if you decide to go to a movie theater or go to any other indoor event with lots of people, say, for example, like a party at the White House, that's the time to mask up.
We all suffer from making masks more politicized than they need to be. Our arguments about wearing them should be intellectually honest about the benefits as well as the risks so that we can avoid turning mask wearing into virtue signaling.
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