The Facemask as a Political Football

This 1656 engraving by Gerhart Altzenbach depicts a plague doctor wearing the personal protective equipment of the time, derived from French doctor Charles De Lorme’s original design. MEDICAL HISTORY LIBRARY, HARVEY CUSHING/JOHN HAT WHITNEY MEDICAL LIBRARY, YALE UNIVERSITY

An epidemic of plague in France in 1619 resulted in the first medical mask. A French doctor, Charles De Lorme, invented an early prototype of a hazmat suit, including a cape, boots, hat, and a strange bird-like mask. (Figure) Doctors used the stick to maintain an appropriate distance from their patients. The mask’s beak contained flowers, herbs, and ingredients such as viper flesh powder to purify the inhaled miasma; corrupt air thought to cause the disease. This concept predated the germ theory of illness. Miasma was the period’s explanation of the source for what were infectious diseases. The plague swept through Western Europe, and the outfit remained in use for more than a century. Medical professionals wore it during 1656 outbreaks in Italy, the 1665 London Plague, and the Great Plague of Marseille in 1720. Not surprisingly, the mask was mocked as useless. Since the death rate was circa 30%, futility prevailed. However, Dr. De Lorme instinctively had the right idea.

First published Mar. 15, 2022

Governor Ron DeSantis of Florida displayed his ignorance and arrogance when he visited a Florida school during the covid-19 epidemic and, irrationally and cruelly, chastised students who were wearing masks. The voters of Florida need to be more discriminating. As the saying goes, “One cannot expect an ass to look in the mirror and have an apostle look back!”

The science of the use of facemasks to prevent infection is contingent on three principal factors:

(1) Is the infection spread by a respiratory route, that is, by the expulsion of infectious particles from nose or mouth and transfer to another person usually by inhalation of those particles? If so, masks can be very important in reducing risk of infection.

(2) Are the particles so-called droplets, which term indicates they are relatively large? The latter type fall to the ground quickly and are not as likely to spread person to person, if a distance intervenes. Hence, the choice of a six foot minimum for social distancing. Some make the case for a greater distance. Shouting or coughing markedly increases the distance droplets and aerosols travel. In addition, if the virus particles contained are short-lived or relatively few, they, usually, are not spread by hand, touching surfaces and the like. This latter case is true of SARS-CoV-2, the viral cause of covid-19. SARS-CoV-2 is not transmitted via fomites. [ A “fomite” is any inanimate object that, when contaminated with an infectious agents (e.g. pathogenic bacteria, viruses or fungi), can transfer disease to a new host usually by hand to mouth or eye.] If the airborne particles are small they are referred to as aerosols and they can hang in the air for prolonged periods, many minutes and are more likely to be inhaled by a nearby person or float across rooms, akin to cigarette smoke, if the air exchange is not of high quality. This fact explains the decreased risk of the outdoors, where air currents disperse the aerosols, reducing the risk of inhalation or the dose of infectious particles inhaled. After a bit of debate, SARS-CoV-2, it is agreed, usually is spread by droplets and aerosols.

(3) The third factor is the quality of the mask. Is the mask manufactured to decrease the risk of both large (droplets) and small (aerosols) respiratory particles? That type is the ideal. Hence the recommendation of the N95 mask or its equivalent.

The other factor related to a mask is its fit. The mask should fit properly around the cheeks and nose and the chin so as to prevent particles from being inhaled through gaps. With the best masks worn properly, the risk of transmission of spread of SARS-CoV-2 is significantly reduced. Even in a real world setting, where mask quality is uneven and their fit uneven, the decrease in infections is substantial, at least in half. When used properly, coupled with distancing and avoidance of high-risk environments, there effectiveness is dramatic.

The damaging effects and risk of SARS-CoV-2 infection are strongly correlated with age, especially over age 60, when comorbidities (immunodeficiencies, diabetes, lung, heart and kidney disease, cancer therapy and others) and a decreased immune response as a result of aging are common. The risk of hospitalizations and deaths from covid-19 is very strongly correlated with increasing age over 60 years. The risk of severe disease to the younger individual is much lower, but not zero. These facts should be made known widely and those who are concerned about their health risks should be encouraged to wear masks and avoid high-risk environments, e.g. indoor crowded spaces and persons who mingle widely and may have a high-risk of exposure and the unvaccinated.

The decision of politicians to make mask wearing for health reasons a political issue is a reflection of ignorance, pettiness and insecurity: not characteristics that should garner votes. Instead, politicians, charged with fostering the public good, should encourage their use as needed by the age, health status and circumstances of the individual. Indeed, a case can be made for the same approach during the flu season and, especially, if the flu strain is widespread and virulent. The aged and residents of senior living communities should not necessarily use the CDC guidelines. The latter are aimed at the average U.S. citizen and the need to consider maintaining commerce in its recommendation. Providing strong guidance, based on age, health status and circumstances is to everyone’s benefit. Residents, acting for the good of a close-knit community have an obligation as citizens, friends and neighbors to behave sensibly to decrease the likelihood of spread of infectious agents.

In recent acts stimulated by ignorance and the fear of rational behavior in favor of machismo, legislators in some states are instituting bans on the use of masks. Apparently, Nassau County in New York State is one such community dominated by political nitwits. The Founding Fathers, wisely, did not include in the Bill of Rights, “If respiratory infectious disease is spreading widely and killing people, you have the right to do whatever the hell you want.”