Masking: A Careful Review of the Evidence

Masking: A Careful Review of the Evidence

Paul E. Alexander MSc PhD et al

The question on whether to wear a face mask or not during the Covid-19 pandemic remains emotional and contentious. Why? This question about the utility of face coverings (which has taken on a talisman-like life) is now overwrought with steep politicization regardless of political affiliation (e.g. republican or liberal/democrat). 

Importantly, the evidence just is and was not there to support mask use for asymptomatic people to stop viral spread during a pandemic. While the evidence may seem conflicted, the evidence (including the peer-reviewed evidence) actually does not support its use and leans heavily toward masks having no significant impact in stopping spread of the Covid virus. 

In fact, it is not unreasonable at this time to conclude that surgical and cloth masks, used as they currently are, have absolutely no impact on controlling the transmission of Covid-19 virus, and current evidence implies that face masks can be actually harmful. All this to say and as so comprehensively documented by Dr. Roger W. Koops in a recent American Institute of Economic Research (AIER) publication, there is no clear scientific evidence that masks (surgical or cloth) work to mitigate risk to the wearer or to those coming into contact with the wearer, as they are currently worn in everyday life and specifically as we refer to Covid-19. 

We present the evidence in full below. We also state that should adequate evidence emerge that supports the effectiveness of surgical and cloth masks in this Covid pandemic (or any similar type masks), then we will change our position and conclude otherwise. Our focus is on face masks for  Covid but we will touch gently on the issue of school closures and lockdowns, as these three issues remain the key public health policy catastrophes we have faced as global societies. 

Back in August 2020, a survey by Pew indicated that 85% of Americans wore masks when in public all or most of the time. So, the public has been using masks extensively. We thus set the table in this review on the effectiveness of masking for Covid by asking, if these surgical and cloth masks are effective, why did incidence of the virus (or actual disease; and they’re not the same thing) escalate so rapidly despite widespread use? Why is there no evidence across US States and global nations showing that when use is mandated (or not mandated given the general uptake of masking by the public), this contributes to reduced viral transmission? Is there any such evidence? 

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Where do we begin on masks? How about infection fatality rate/IFR?

Moreover, we are addressing here highly irrational, punitive, capricious, and groundless societal restrictions for a virus with an infection fatality rate (IFR), based on Stanford University John Ioannidis’s calculations, of 0.05% in persons under 70 years old (across different global nations). There is even a recently reported noninstitutionalized IFR in Indiana in those > 12 years and up to 60 years of age (reported in the Annals of Internal Medicine) of 0.12 (95% CI 0.09 to 0.19), and an IFR for less than 40 years old of 0.01. These are mortality estimates that are at or below those of seasonal influenza. 

So why would we continue this way with these unsound and very punitive restrictive policies and for so long once the factual characteristics of this virus became evident and as alluded to above, we finally realized that its infection fatality rate (IFR) which is a more accurate and realistic reflection of mortality than CFR, was really no worse than annual influenza? 

How did we get here? 

How did we arrive at the confusion and misinformation surrounding mask use which is our focus, yet by extension, the crushing societal lockdowns and harmful school closures? There are serious harms and downsides due to these crushing restrictive policies and we understand that one would think reflexively if there is a pathogen, we should just lock and shut everything down and away. We understand this initial instinct. 

However, there are benefits and risks to any action and the harms of these lockdowns and school closures far outweighed the benefits based on what has transpired. We even knew this soon after implementing lockdowns yet we continued catastrophic policies and are still continuing. How did we get here societally? How have our government bureaucratic leaders failed so disastrously? 

We lay heavy blame on our government leaders but argue that the so-called ‘medical experts’ who are part of Covid Task Forces and guidance panels have been largely unscientific, illogical, and irrational in their guidance and statements. 

Untethered from the reality of things. In many instances just flat out misleading and wrong! The incessant campaign by the media that has worked to drive fear and hysteria in the public is also partly to blame. There appears to be an unholy alliance between the government bureaucrats, the aforementioned ‘medical experts,’ and a willing print and digital media. A vast lot of what these experts say on Covid makes no sense anymore, at times unhinged and lacking of any credibility. 

In such incredibly important  Covid-related input and guidance, these television medical experts and many government leaders have failed in profound and often unimaginable ways and we are left asking how they got things so very wrong. Is it that these medical experts do not read the science? Or maybe cannot understand the data or science? Which? They talk about following the science but seem blinded to it. They clearly don’t follow the science else we would not be here. They seem to not understand the devastation they have visited upon the lives of so many. 

We argue that the messaging by the media and medical experts initially suggested that all persons are of equal risk of severe illness from Covid infection. This is where it all went wrong and where societies were greatly deceived by those who should not have done that. We were never ‘all’ at equal risk. This was deeply flawed and has crippled the US and global nations since day one of this pandemic. This was and remains a flat-out falsehood (untrue) and it has driven irrational fear by the public. This clearly erroneous intimation has stuck in the minds of the public and severely impacted the public’s perception of their risk and how they would move forward. 

School closure policy mirrors face mask policy?

What did we know? Let’s address masks by first looking at school closures as it bears mentioning about the disaster the flawed school closure policies directed by our government leaders have caused in our children’s lives. The school closure catastrophe mirrors the masking catastrophe and similar unsound policies. We knew early on in 2020 for example, that the key risk group was elderly persons with medical conditions (though Covid gave way to age due to serious medical conditions or obesity based on existing data). But just look at the complete disaster experts have created with our children in terms of school closures. 

Look at what is now known in Ontario, Canada with the union and fees paid to ‘conflicted’ medical experts to drive a school closure message. This is reckless and scandalous! In spite of extremely low transmission rates and very low likelihood of spreading Covid virus among children (or of becoming severely ill from Covid), they have gone on and destroyed a year of the school lives of children due to these nonsensical medical experts and hysterical media and this will carry a huge long-term loss to our children. Who is going to pay for this? 

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Questions on masking mirrors questions on social distancing?

Specifically, from what sources did the CDC rely upon to designate that a distance of 6 feet between individuals is needed to mitigate Covid viral spread? And why, for example, do Europeans from various countries only have to stand about 1 meter apart (approximately 3 feet)? Do they know something that we don’t? Or were both values arrived at arbitrarily? Were these recommendations based on evidence or were they set arbitrarily? If the latter, then why not 4 feet, 10 feet or 20 feet? Turns out “the World Health Organization recommends a distance of “at least one meter (3.3 feet).” China, France, Denmark and Hong Kong went with one meter. South Korea opted for 1.4 meters; Germany, Italy and Australia for 1.5 meters. 

The CDC said 6 feet and we still don’t know how they arrived at this distance and yet this pandemic has been active since at least February 2020. Unfortunately, then we can similarly at best only make unsound and disingenuous statements in favor of the use of masks but which are not backed with evidence or data. Yet the issues at hand are so serious given large societal implications and reorganization that it is difficult to reconcile with logic the absence of any such studies. 

Focusing on face masks

With a focus on facial masks, where do we stand? Well, our position is based on the science. We contend that surgical and cloth masks are basically facial coverings that lack any scientific data to support their use. And that they are largely cosmetic and function more to give the user a sense of confidence and security as it pertains to the Covid pandemic. We are basing this on an examination of the totality of the evidence to date presented below. Except for the N95 masks (typically for hospital and high-risk settings and usually accompanied by gowns, gloves and other PPE) and only when properly fitted to allow for an optimal seal to the face, and only when changed often, is there effectiveness in mitigating respiratory virus spread. 

And in relation to this, such protection is generally required only when clinicians treat highly infectious patients and under isolation conditions! Effectiveness also depends on a filter that could effectively deal with virus-sized particles. The Covid-19 virus is 120 nanometers in size while the filtration potential of a N95 mask is 150-300 nanometers. We also suggest that such fitting would actually be needed as a person places a fresh mask on their face, in order to retain functionality of the N95 respirator. Perhaps, it is important to note that the “N95” terminology means that the mask filters 95% of the particulate material. Moreover, prolonged use of fitted N95 type masks (particulate filtering facepiece respirators) are uncomfortable, and can potentially cause harm

In light of the above we hold that most of the populace would favor the use of the typical surgical ‘blue’ masks (or worse; cloth masks or home-made cloth masks) and even considering the fit issues discussed here regarding N95 masks, they cannot provide similar protection (from being infected or passing on infection) as might N95s. 

There is simply no defensible rationale to treat this pandemic other than using an age and risk-targeted approach and fostering optimal hand washing hygiene. The vastly rational and sensible way is to target high-risk people (i.e. those at risk of developing severe disease and/or dying) and allow everyone else to get on with their lives. We ensure hospitals are well prepared (we hope) and we have had one year to do this as outlined by our governments when they asked us to help ‘bend the curve,’ and we simultaneously triple down on protecting the high-risk persons. 

With this in place, we strive to safely and with sensible precautions, reopen society and schools in full. It is as simple as that, and on top of this, we have strong evidence of the use early on of repurposed existing, safe, cheap, and effective therapeutics in higher-risk Covid positive persons in private homes or nursing home settings who are showing initial symptoms. When used early in the outpatient setting, these drugs (sequenced combined antivirals, corticosteroids, and anti-thrombotic anti-clotting drugs) can help reduce isolation, mitigate transmission, and cut hospitalization and death significantly. 

The implications of the policies like restrictions and masking are far-reaching and such policies must be based on evidence. The current policies cause crushing harms to our societies and cannot be based on the notion of stopping Covid at all costs. Stopping Covid at all costs without factoring in the implication societally is a completely illogical, irrational, damaging, and unattainable goal. 

Asymptomatic spread and masks? 

Before proceeding to the key evidence on the effectiveness (or not) of face coverings (masks), we wish to highlight research that is highly applicable. This surrounds recently emerging evidence that  Covid-19 spread is so exceedingly rare in asymptomatic persons as to have virtually no impact in the grand scheme. Given that there are very strong data to support this contention, then we state at the outset that universal masking has no merit and cannot be supported by reliable data or research. 

In an article published in Nature Communications (November 2020) that studied 10 million eligible persons, it was demonstrated that asymptomatic spread was not merely rare but in fact, does not appear to happen at all! Not one instance was found in the study whereby researchers reported that there were positive tests emerging even amongst close contacts of asymptomatic cases in this sample of 10 million. Why would we even consider then the need for universal masking when there is evidence like this of limited asymptomatic spread? 

We also point out (and we also recognize and appreciate that this argument is far from being one based in strong evidence per se) that if ten’s of studies or more are required to prove, one way or another, whether a procedure is effective or not (and to therefore lead to changes in standard of care), and there are still no reliable data, the effects are either minimal or nonexistent. Hence it can be reasoned that there is no meaningful effect in the first place; such an argument can be used for the masking dilemma. 

All this is to say that there is and was no scientific justification to mandate or call for ‘voluntary’ masking of healthy people. None! And we also suggest that this straightforward reasoning can be applied to most of the other ‘mitigation’ efforts being implemented to date; specifically societal lockdowns, and school closures. In fact, we can find no definitive research-based evidence to support masking, societal lockdowns, or school closures at the time of writing this piece. We continue to argue that most of this has been arbitrarily construed by the government leaders and their medical experts. 

These policies are not merely misguided, but they are also not without serious and adverse consequences; they have caused crushing harms and have been very injurious at a personal and societal level. Restrictive policies have not been thought through as to the implications at large! The benefits have not been assessed or considered alongside the potential (and documented) harms and this is a catastrophic omission from the perspective of sound public health policy and principles. In short, the bureaucracy has provided us with confused and often contradictory policy supported by a lack of clarity, sheer assumptions, and nonsense in general, and in this case, in relation to universal masking. Our leadership and ‘experts’ have failed to recognize the crushing harms that result from their arbitrary and even worse, capricious policies that lack any reliable evidentiary support!

It might also be expected that in light of the apparent groundbreaking seminal research to which we alluded above, this would not only be covered widely by the mainstream media and of course our experts but that this would clarify and help settle issues pertaining to asymptomatic spread, lockdowns in general, school closures, and of course in this case, masking. Amazingly though, there has been no acknowledgement of this work. And yet such findings that could bear on evidence-informed decision-making were ignored entirely. 

Double masking? 

Moreover, Dr. Anthony Fauci of the NIAID is now supporting (or at the least not discouraging) the call for the use of double masks! To paraphrase him, it makes ‘common sense’ to wear two masks instead of one. Yet this flies in the face of the extant data showing that the use of single masks has not provided any protection insofar as progress of the pandemic is concerned (in fact just the opposite… in virtually every jurisdiction in which mask wearing was mandated, there were very large increases in the rates of infection or at least PCR positivity to be more accurate). Despite this Dr. Fauci has responded by raising the double-mask approach, stating that “it likely does” work in relation to offering more protection. 

What happened to “following the science” and the need for randomized controlled trials on the use of double masks? It seems that we follow the science only when it supports preconceived notions or goals. What was stated on double masking was utter nonsense. Dr. Fauci likely did not read the marine recruit CHARM NEJM study whereby the recruits consistently wore double layered masks yet there was still spread in the most heavily, monitored for compliance, and restricted to military environments. 

Did Dr. Fauci also consider the possibility that with double masks, wearers will likely experience more difficulty in simply breathing comfortably? And what would be the consequences for those with pulmonary diseases, upper respiratory infections, others with difficulty breathing without a mask, and most importantly for children? Wearing a mask, let alone two, potentially simulates COPD/chronic obstructive pulmonary disease, akin to what smokers commonly get. Masks can make it difficult for one to breathe out, especially during stressful situations. We cannot say here because we don’t know, absent scientific data, but neither does Dr. Fauci. At worst the advice regarding the use of double masking (why not triple or even four or five masks?) is arbitrary and has no scientific basis. Then why put it out there? This reflects a dissonance to anything that disrupts the set narrative that at this stage of the pandemic happens to be more political in our view than scientific or evidence-based. To add to the confusion, Dr. Fauci followed this up by stating when questioned about this statement by the media, that there is no data to show that double masks work. So, what then is the public to believe? We cannot claim to think for Dr. Fauci and similar medical experts, but why do medical experts with a podium consistently in this Covid pandemic lend so much misinformation and confusion to the public?They consistently make statements with no data or evidence to back it up. They cause great confusion and distrust by this. 

Mask mandates? 

As noted above, the data show that Dr. Fauci’s confusing about-faces concerning advice as to management of the pandemic issues, including on masking, was perhaps arbitrary at best. As regards to masking, it is simply impossible to understand ongoing recommendations for this when we know that there are multiple US States where it can be shown clearly that after implementing mask mandates (indoor and outdoor), the number of cases went up! We are not suggesting that the addition of mask mandates in any way caused case numbers to soar, but clearly they had no positive or beneficial effects either. There are 37 US states including but not limited to California, Texas, Hawaii, Maine, Delaware, Florida, Oregon, and Pennsylvania that currently mandate face coverings in public. Outside of the USA, there are also global data showing that when mask mandates were implemented in Austria, Germany, France, Spain, UK, Belgium, Italy, to name only a few, case numbers went up, not down

Moreover, the EPOCH Times reported that “in states (US) with a mandate in effect, there were 9,605,256 confirmed Covid-19 cases, which works out to an average of 27 cases per 100,000 people per day. When states didn’t have a statewide order—including states that never had mandates, coupled with the period of time masking states didn’t have the mandate in place—there were 5,781,716 cases, averaging 17 cases per 100,000 people per day; a notable reduction as compared to the number of cases observed during mask mandates! States with mandates in place produced an average of 10 more reported infections per 100,000 people per day than states without mandates.” The blind acceptance of the current unsupported dogma that has become so entrenched that if cases do go up, the experts wedded to the universal use of masks claim that this is good news such that the masking prevented even more cases from occurring; this is truly incredible.

The reality is that there is significant evidence that masks are not effective for controlling a pandemic. To reiterate we agree, though, that within the context of a clinician treating an obviously infected patient (with any communicable disease), the use of masks is important but even then this must also be augmented by the use of other PPE (goggles, and even hazmat clothing with isolated oxygen supplies for example) and this simply cannot be compared to population wide use of masks The effects on populations are catastrophic and masks, perhaps unintentionally have constrained our ability to return to a semblance of normal life

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