To Mask or Not To Mask…
By I.M. Doctoo
I recently read a self-professed rant from a person identifying themselves as a surgeon, berating people who object to wearing masks. It’s a classic “appeal to authority” argument with the ranter holding up their own experience as a surgeon as authority regarding masks. There are, however, many shades of accuracy in the argument, and the “surgeon” really shows some gaps in their medical knowledge… not to mention their compassion.
In the hopes of leavening the panic with a bit of counterargument and facts from ANOTHER medical professional viewpoint – here’s MY rant in response to:
“… here’s my rant about masks…”
As is customary in such things, the original article is in italics, my response is in bold. I’m withholding the name of the OP doc for obvious reasons.
I have spent the past 39 years working in the field of surgery.
Good for you. That makes you an expert in surgery. Not physiology, not immunology, not virology, microbiology, or epidemiology. Also, given the name provided in the original article, plus additional information such as “39 years” and retired, we can paint a fairly good picture of this person: Male, age 65+, very likely a 10-15% body fat, tall, lean and fairly fit Caucasian (based on demographics of medical students pre-1980). Their most likely vices were nicotine and caffeine – and to have lasted 39 years as a surgeon, they likely gave up smoking in the 90’s when it became prohibitive for docs to smoke – and likely only recreational alcohol use except for college and the occasional vacation.
So, we have a mental image of our “ranter.” This is important for some later comments.
For a significant part of that time, I have worn a mask. I have worked with hundreds (probably thousands) of colleagues during those years, who have also worn masks. Not a single one us of became ill, passed out or died from lack of oxygen. Not a single one of us became ill, passed out or died from breathing too much carbon dioxide. Not a single one us of became ill, passed out or died from rebreathing a little of our own exhaled air. Let’s begin here by putting those scare tactics to rest!
This is anecdote, not science. But aside from that, let’s start with what masks this surgeon was wearing: A standard surgical mask is a thin paper (or synthetic fiber) weave designed with a pore size of about .1-.3 microns to stop the medical professional from sneezing or coughing on the surgical field. It’s lightweight and did I say thin? About the same weight and thickness as a single layer of lightweight fabric.
Now let’s talk about what the CDC and NIH guidelines say about effective cloth masks: “Multilayer fabric consisting of a high thread count cotton outer layer, two layers of batting, and an inner ‘comfort’ layer of flannel.” By the way, that’s not a bad composition for filtering. It has small pores, a “tortuous” pathway for the air to flow and the flannel (or silk if you prefer) provides an electrostatic effect that can help filter more particulates. Except for one small thing – the pathway is designed to filter INCOMING particles. To perform the task of filtering sneezes and coughs, you only need the simplest of barriers. But more on that later.
Now let’s talk about what our surgeon was doing during those hours in surgery:
He was standing still. In one place, while the nurse handed him all of his instruments.
They were not walking, climbing steps, hurrying into the store, carrying a child, hauling groceries, etc. No, in fact, moving around the surgical theater is contraindicated and increases the chances of contamination. So, he stood still performing surgery. For hours at end, with little to no change in rate of breathing or airflow the whole time. Most likely the moment he could escape the OR – that mask was OFF! In fact, hospital and OSHA regulations said that the mask MUST come off the moment one leaves the contaminated field. Because that’s what a patient area is… a contaminated space.
So, our surgeon actually has NO idea how if feels to wear a mask in any situation other than standing still for hours at a time. Again, this is important to his rant.
- JUST. DOESN’T. KNOW.
He doesn’t have the experience, and some statements further down suggest that he doesn’t retain the medical knowledge either.
(It is true that some people, with advanced lung diseases, may be so fragile that a mask could make their already-tenuous breathing more difficult. If your lungs are that bad, you probably shouldn’t be going out in public at the present time anyway; the consequences if you are exposed to Covid-19 would likely be devastating.)
So this statement shows a profound insensitivity and arrogance. “Already tenuous breathing?” How would he know? Again, his personal experience is negligible, and he proves himself to be ignorant of basic physiology with this comment. A “normal” person can have breathing difficulty without their lungs being “that bad.” I personally have an airway issue from a double-fractured septum. It reduces the airway diameter and increases the speed air flows through my nostrils. It is differentially affected by various mask materials – It’s fairly simple to test O2 saturation during recovery from exertion. If you have a sportswatch, it likely has an O2 test (look for “stress”) some of them use a relative scale, but again, a reasonable test is to go up and down the same flight of stairs three times, quickly. Do this test without a mask. Before the first trip, check your blood O2 saturation (or stress level – it uses heart rate and O2) – then make the three trips and then check O2 every minute until it returns to normal/pre-test level. Now do it again with a mask. For me, it takes about twice as long to come back to normal with a thin surgical mask – even longer with a cloth mask.
So yeah, O2 recovery from exertion is a thing, and it’s affected by masks. You need higher airflow with more physical movement. THIS IS WHY PEOPLE ARE ADVISED TO NOT EXERCISE WHILE WEARING MASKS! Duh. It’s different than simply standing still in one place for hours.
Surgeon 0, Science (common sense and compassion) 1.
The reason this comes up is because filtering virus particles and other microorganisms requires one of two things – either (1) pore sizes smaller than what is being filtered – or (2) a tortuous path that performs the same function by causing airflow to change directions. With the latter, small particles don’t change directions as easily as gases, so they run into the fibers of the mask and get trapped. [By the way, this is why used masks need to be disposed or sanitized.] Surgical masks use technique 1, and air flows fairly easily. EFFECTIVE cloth masks use technique 2, and they definitely alter airflow.
My favorite source for data on mask composition (and it’s a good one – these are real benefits of proper mask wear and construction) is: https://pubs.acs.org/doi/10.1021/acsnano.0c03252. They report both filtration efficiency based on particle size, as well as the differential pressure drop. The pressure drop through the various mask materials doesn’t seem significant – 3.0 Pascals (Pa) for multilayer/hybrid cloth masks vs. 2.2 Pas for an N95 or 2.5 Pa for a surgical mask… until one realizes that (1) it represents 15-25% increase in resistance, and (2) the flow rate they tested – 1.2 cubic feet per minute (CFM) is around half of the normal RESTING breathing rate of a human (60 liters/min which equals roughly 2 cfm) whereas just WALKING typically results in flow rates up to 5x higher (300 liters/min). Now – there’s something important here – and that is that pressure drop increases with the square of flow rate (It’s called Bernoulli’s Principle). Fast walking, going up stairs, carrying a load (like an infant) means a 10x increase in airflow from what was tested. 10x airflow means 100x the pressure drop. So now the 3 Pa pressure drop for a cloth mask becomes 300 Pa drop. That may still seem insignificant compared to atmospheric pressure (100,000 Pa), but consider this – a standard CPAP setting of 10 = 1000 Pa – so the amount of pressure drop from a mask under these conditions is about one-third the pressure of a CPAP!
So – yes, masks DO cause a drop in pressure.
Surgeon 0, Science 2. The only reason our surgeon ranter never experienced a pressure drop is because he was STANDING STILL!
~ “But”, you ask, “can’t viruses go right through the mask, because they are so small?” (“Masks keep viruses out just as well as a chain link fence keeps mosquitoes out,” some tell us.) It is true that individual virus particles can pass through the pores of a mask; however, viruses don’t move on their own. They do not fly across the room like a mosquito, wiggle through your mask like a worm, or fly up your nose like a gnat. The virus is essentially nothing more than a tiny blob of genetic material. Covid-19 travels in a CARRIER – the carrier is a fluid droplet- fluid droplets that you expel when you cough, sneeze, sing, laugh, talk or simply exhale. Most of your fluid droplets will be stopped from entering the air in the room if you are wearing a mask. Wearing a mask is a very efficient way to protect others if you are carrying the virus (even if you don’t know that you are infected). In addition, if someone else’s fluid droplets happen to land on your mask, many of them will not pass through. This gives the wearer some additional protection, too. But, the main reason to wear a mask is to PROTECT OTHERS. Even if you don’t care about yourself, wear your mask to protect your neighbors, co-workers and friends!
OKAY, this is Point Of Failure Number Two. Sorry, Doc, but you just FAILED virology 101.
Because what you’re talking about is AEROSOL – that’s viruses trapped in droplets of snots and spit. However, COVID19 is also AIRBORNE! So yeah, they DO “fly across the room” – well, they actually float. Like dust motes. Dust particles as large as 2-5 microns float in air – in fact, you can see them indoors in still air illuminated in a beam of sunlight through a window. Two-to-five microns is pretty big compared to a virus. The coronavirus particle is around one-tenth of a micron. [Hint: watch how long cigarette smoke hangs in the air – it’s a similar size.]
So yeah, individual virus particles can float, and guess what? They can get through that mask… any mask.
Surgeon 0, Science 4
The good news is that the virus doesn’t last long in air. Yes, it survives more in aerosol droplets – but to understand why airborne virus is an issue – think about where the virus lives. Docs test you for COVID19 by taking a swab from the back of the nose. They’ve found that even in some people not showing symptoms (and especially people showing the first symptoms – the amount of virus in that area is significant. That means that you don’t have to sneeze of cough to release coronavirus. You just have to breathe out. That puts airborne virus in the air.
Especially floating past the fibers of that surgical mask or a single layer cotton mask (or worse, macramé or sock material!). Have you ever walked past a smoker while wearing your mask and smelled the smoke? Then your mask is not filtering. Cigarette smoke particulates run from .1 to 1 micron, typically. If they can get through your mask, then so can an airborne virus!
Now aerosol droplets are pretty large typically more than 1 micron – and in cases of coughs and sneezes – MUCH more than 1 micron. The CDC itself (https://www.cdc.gov/niosh/topics/aerosols/pdfs/Aerosol_101.pdf) says that the time required for a particle to settle out of air depends on its size – a 100-micron droplet (spittle) settles out in about 6 seconds. 10 microns (sneeze) in 8 minutes. Half a micron (virus and some bacteria) or smaller? More than 2 days.
The large size also means they are more easily filtered. Cheap, low thread count cotton or polyester will filter most particles above a micron in size – so in reality, a mask made of the thinnest material is sufficient for preventing your own aerosol droplets from getting out.
The problem is that if the goal is stopping the virus, it’s not enough. If you are infected, you’re emitting both aerosol and airborne virus.
Now, if I were inclined to be charitable, I’d say that our surgeon just suffered from oversimplification. *IF* – we’ll see, though.
~ A mask is certainly not 100% protective. However, it appears that the severity of Covid-19 infection is at least partially “dose-dependent.” In other words, the more virus particles that enter your body, the sicker you are likely to become. Why not decrease that volume if you can? “What have you got to lose?!”
Masks are still effective, right? Well, yes and no. No comfortable mask is going to filter the airborne virus. It WILL filter aerosol. Yes, but the simplest/thinnest mask will do that – but not the airborne virus – because despite his protestations to the contrary, our surgeon ignored one of the infection routes for the virus… and that’s a serious failing.
By the way, the vaunted N95 masks do NOT filter exhalation. They are strictly to protect the WEARER, and not the public, as is particularly discussed on social media. N95’s have an exhalation valve that allows exhalation out, but closes when you inhale so that the air is filtered. That’s not going to stop a sneeze. So forget about your cloth mask being equivalent to a doctor’s N95 – it’s much more like the paper-thin surgical mask which we already show can’t filter all of the virus (especially not when it includes straw holes, breathing flaps, or is worn below the nostrils!).
But here comes that kicker… “what have you got to lose?” Well, even the thinnest of masks can be problematic for some people. If you have reduced airway, you need higher airflow – masks by their very nature reduce airflow. Our surgeon may not have noticed it, but it happened. It’s just wasn’t critical for the activity he was engaged in. There’s other biological imperatives – people with beards or facial deformities can’t get a good seal. Persons with a psychological issue (like a rape experience, claustrophobia, feeling of being trapped, etc.) can’t wear something over mouth and nose – it causes panic attacks, higher respiration rate, and problems with O2 saturation. [By the way, if you have to sleep with a CPAP, your airway is prone to collapse when airflow is reduced – so you probably shouldn’t be wearing a mask that restricts airflow! See above that the effective pressure drop with high flow rates from mild exertion begin to approach the pressures of a CPAP machine!]
But he doesn’t address that, preferring instead to take the arrogant normative male position of “What have you got to lose?”
The answer – is that we have a hell of a lot to lose because it’s possible to be airway compromised and still need to go to the store for groceries (hint – not every place delivers or can pick exactly what you ask for from an online order)!
Surgeon 0, Science (and compassion) 5
~ “But doesn’t a requirement or a request to wear a mask violate my constitutional rights?” You’re also not allowed to go into the grocery store if you are not wearing pants. You can’t yell “fire” in the Produce Department. You’re not allowed to urinate on the floor in the Frozen Food Section. Do you object to those restrictions? Rules, established for the common good, are component of a civilized society.
TWEET! Penalty on the play! Red Herring and false analogy! You’re really going to equate wearing a mask with pissing on the floor?
That’s pretty damned arrogant; not to mention privileged.
Penalty assessed: Surgeon -1, Science 5.
He’s right in a way, though, but that’s why I didn’t take away two points for the blatant Red Herring Fallacy (https://thebestschools.org/magazine/15-logical-fallacies-know/). We don’t have the right to impair the health of another. Unfortunately applying that concept to masks misses two important points – the impact on the health of the wearer, which can be physical or psychological – and the blind assumption that anyone not wearing a mask is spreading COVID19.
So – that’s Failure Three. The evidence on this last assumption is still in debate. The initial data that said COVID was spread by asymptomatic individuals was based on contact tracing and data from China. I’m not saying China was lying, but a lot of their data is incomplete and/or inconsistent. Frankly, we should not be relying on it. There’s other data, though – the Skagit Chorale case (https://www.cdc.gov/mmwr/volumes/69/wr/mm6919e6.htm) showed 53 of 61 members of a choral group were likely infected from one “superspreader” who was presumably asymptomatic at the time. HOWEVER, there’s been no positive identification of the person who brought the infection to the group other than one person who had reported cold-like symptoms that started four days before the second of two rehearsal sessions the group had in common.
This case *looks* like a classic case of asymptomatic spread… but it isn’t it’s undefined.
Now let’s look at Hamburg Germany – a businessperson from China attended a meeting, and later 2/3 of the attendees tested positive with no other contact in common other than this “asymptomatic” person who subsequently tested positive after return to China.
Another asymptomatic spread, right?
Nope. The case study has been challenged in the scientific literature because it turns out that other evidence surfaced showing that the “asymptomatic” person was actually symptomatic and sought some “cold relief” prior to the meeting.
Then again, we DO have cases that can ONLY have been transmitted from people showing little to no symptoms. The aforementioned high nasal virus tests have occurred in asymptomatic persons, and they are likely spreading virus. On the other hand, data from northern Germany, Iceland, Sweden, S. Korea, the Diamond Princess Cruise ship, all point to a high percentage of positive tests resulting in little to no symptoms (as high as 90% asymptomatic) and low transmission FROM those presumed asymptomatic individuals (<40% of cases).
You’ll notice the caveat about “presumed asymptomatic cases” because this factors in one other of the scientific reports on asymptomatic transmission. The prestigious Scripps Research Institute published a meta-analysis on asymptomatic spread (https://www.acpjournals.org/doi/10.7326/M20-3012) that again repeats the 40-45% value regarding spread of the disease from asymptomatic patients. The problem with this paper is that it is a meta-analysis – it reads existing reports, puts it into a combined analysis, and generates conclusions. The problems are (1) it is not a controlled clinical trial or study, (2) it relies on the accuracy of the reports used in the study, and (3) it is based on some studies with ridiculously low counts of asymptomatic subjects – in fact, two of the five “longitudinal” databases include 3 and 4 “positive but asymptomatic” subjects, respectively! In addition, there are at least three databases that are homeless or inmate populations that ignore the very evidence of “superspreaders” such as shown by the Skaggit Chorale study
There is a saying in computer science that fits here: “Garbage In, Garbage Out.”
The only conclusion we can come to is that asymptomatic individuals MAY spread COVID19 – but if they do, it’s probably only accounting for around a third of the cases.
The one that CAN be gleaned from the Scripps meta-analysis is that each population that showed high likelihood of spread in the absence of symptoms – involved hours, if not DAYS of contact. You know – like in jails, nursing homes, cruise ships… etc. Precisely the groups that social distancing – without masks – is supposed to address! In fact, the authorities blame the 2.5-hour rehearsals and singing (with aerosol droplets, no less) for the Skaggit Chorale superspreaders.
~ “But aren’t masks uncomfortable?” Some would say that underwear or shoes can be uncomfortable, but we still wear them. (Actually, being on a ventilator is pretty darned uncomfortable, too!) Are masks really so bad that you can’t tolerate them, even if they will help keep others healthy?
TWEET! “Think of the children ploy!” Also known as “Appeal to Pity.” Yes, you’re doing it for others… except there’s no solid evidence that you are “keeping others healthy,” and plenty of evidence that mask wearing can cause psychological harm to others.
But yes, the whole argument is that we need to wear masks FOR OTHERS while ignoring the fact that some people CANNOT and should not wear masks.
Surgeon -1, Science 6
I can just hear it now: “But how will we know the difference?” bleats the masked person in line behind you at the grocery store? “How do we know if the person not wearing a mask is doing it for a valid medical reason?”
Sorry, but you don’t It’s a matter of trust, which is sadly lacking in society these days.
If you are an individual – you might ask “Psst, why are you wearing a mask?” Well, you can ask, but you are not entitled to an answer. It’s considered private – or in technical terms, PHI – Protected Health Information. You, as an individual have no right to breach another person’s privacy. You might think it your duty to “protect others” but you are violating the protections guaranteed to the person you are questioning.
Now, if you’re not an individual? You represent a business from grocery store to professional office? You can ask… and all you are entitled to know is “I have a medical reason.”
Not only that, but your business is REQUIRED BY LAW (Americans with Disabilities Act) to make a reasonable accommodation for another person’s medical disability. But you aren’t entitled to any more than a notification of that disability (and what accommodation is required – although I would think that not wearing a mask is its own explanation).
45 CFR 164 is the relevant section of the US Code of Federal Regulation and it covers the rights to privacy with respect to your personal health information and the penalties for disclosing PHI, or forcing a person to involuntarily reveal PHI. It triggers a fine for companies, and it’s steep. For the common citizen? Basically, all you’re entitled to is silence, but if you push the issue, you may find yourself subject to other reactions.
~ “But won’t people think I’m a snowflake or a wimp if I wear a mask?” I hope you have enough self-confidence to overcome that.
TWEET! Ad-hominem attack! Y’know, Doc – if you’re resorting to this, then you probably already know how weak your argument is!
Surgeon -10 (this was a low blow), Science 6
~ “But won’t I look stupid if I wear a mask?” I’ve decided not to dignify that question with an answer!! 📷🙂
That’s probably wise. Because again, it would be either an Ad Hominem or a Tu Cocque attack and has nothing to do with the science or medicine at stake.
Surgeon -100 (It should have been -1000 because at this point, the surgeon is stooping to every logical fallacy in the books! On the other hand, he didn’t say it, merely implied it), Science 6
~ “But I never get sick; I’m not worried.” Well, then, wear a mask for the sake of the rest of us who are not so perfect!
This is an extremely self-centered approach and a version of the “Sunk Costs” fallacy. “Think of others, but YOUR problems aren’t important!”
There is good evidence that masks make a real difference in diminishing the transmission of Covid-19. Please, for the sake of others (and for the sake of yourself), wear your mask when in public. It won’t kill you!
TWEET! Bandwagon Fallacy!
Well, maybe it won’t kill you – but are you REALLY endorsing causing emotional anguish to the young mother of two with a not-so-benign history with medical professionals? Or the immigrant from behind the Iron Curtain with traumatic memories of the chloroform-laden cloth being held over her face?
This is a case where the Doc’s own experience needs to be brought back up.
There are around 150 medical schools in the US – there’s also about 40 osteopathic schools, and they graduate about 15,000 students each year. Of those, less than 5% go into the surgical sciences (and the associated 6-7-year residencies) – so generously, about 750 new surgeons per year. A 30-year-old surgeon is still an apprentice. 40 is average, 50 is old, and a 60-year old still doing surgery is very rare. So there’s about a 30 year span of practice, so call it 22,500 surgeons in the U.S. at any given time (Physician’s Weekly says 18,000 – but they aren’t including specialties. Statista says 50k surgeons, but again, that would include some who aren’t doing many procedures – they’re teaching and supervising.
But 50k is a good number. Statista also says 500k physician specialists, and around 800-900k active doctors in patient care. Those 50k surgeons thus account for 6-10% of total doctors – and the doctors all total account for 1 in 7000 of the population of the U.S.
So, this brings up an issue with our surgeons “appeal to authority.” He claims to speak for doctors in general, but in reality, he’s just one in 50k of surgeons, and one in one million doctors (active and retired) in the U.S.
Unless he has conducted a controlled clinical trial, with appropriate experimental design and statistical analysis… his position is just anecdote. It’s his experience. He might be able to muster the agreement of a majority of his fellow surgeons or even a large number of doctors, but even perfect agreement would yield only one-third of one percent of the persons in this country.
Worse than that, is that he represents a small demographic. Again, this is a person who completed their medical education pre-1980. The percentage of non-male, fit, 20-something students in med school in the 70’s was very low. My class in 1982 was <20% female. One of the chief complaints with “normal” physiologic measures (body temp of 98.6 F, blood pressure 120/80, heart rate 68, respirations 16, ideal build 5’8″ 168 pounds…) is that it’s an average derived from medical student volunteers in the 50s through 70s.
No matter how he couches it, his experience is no more than anecdote – particularly since his grasp of the fundamental science, compassion and empathy of the practice of medicine is lacking.
P.S. – And, by the way, please be sure that BOTH your nose and mouth are covered!
WOW! Something we actually agree on! And don’t forget to sanitize it!
Recommendations around mask usage are confusing. The science isn’t. Evidence shows that masks are extremely effective to slow the coronavirus and may be the best tool available right now to fight it.”
Yes, they are, but they don’t need to be. Wear a mask if you are sick and can’t simply stay home. Wear a mask if you are at risk. Wear a mask if it makes YOU feel better. But the whole concept of FORCING mask wearing on everybody is as ridiculous as forcing everyone above the age of 2 to wear a bra – for more than half of the population it is totally unnecessary, and for a significant percentage more, it is a matter of choice. Then there’s the ones for whom it is damaging to their own health.
Above all, let it be a personal choice and RESPECT that choice without recriminations. If you are so worried about your own health regarding being exposed to those who aren’t wearing masks… there are things you can do for yourself that don’t involve being a control freak who condones BULLYING other people with fallacious arguments.