What The Pandemic Keeps UnMasking

I have found almost every aspect of the unfolding “to mask, or not to mask while flying” drama to be in equal parts sad and ominous. 

For starters, it’s sad that the opinion of a single federal judge - an individual, whatever the qualifications - would dissuade people from honoring advice from the CDC. Oh, how art the mighty fallen! The question should never have been the legal authority of the CDC; it should have been the moral authority. But sadly, and ominously, the moral authority of the CDC is much diminished. In the context of now quite prevalent disdain, the ruling of an individual about legal authority was sufficient to subordinate the moral authority of the nation’s premier disease prevention institution.

While I have a native appreciation for the CDC, having worked closely with officials there my entire career- I am sympathetic to the current distrust. That the agency, and our leadership in general, were steps behind the pandemic imperatives at nearly every turn is a matter of public record. But more importantly, and ominously, “follow the science” was turned into a defensive barricade behind which ineptitudes of policy and communication could hunker.

Following science is a good idea when science offers clear guidance. When it does not, then the use of science depends on honesty, humility, trust, and the sense to enumerate good options despite lack of certainty, and lack of data. Doubling down on “the science” that isn’t there substitutes dogma for data, diatribe for dialogue. That is alienating. That is an invitation to cheer when a single individual with legal authority kicks pretensions of moral authority to the curb. That is sad, and ominous.

What science is there of the incremental benefit of mask-wearing, on a plane or anywhere else, for individuals who have been vaccinated, boosted, and perhaps had COVID once or more into the bargain? Seriously, if you can quote to me a data-derived estimate of quantitative risk reduction, I very much want to hear from you.

Mask wearing certainly made sense when it was a primary defense in a pre-vaccine world. It made sense before there was any science to invoke. Sometimes sense is all we have; sometimes we have no choice but to follow sense into the gaps of science. Admitting that would likely help gain trust for science when we do have it. Overselling science undermines it. That’s sad, and ominous.

So, to me, the case for masking in the early going was robustly sensible. But now, in the U.S., everyone who wants to be vaccinated and boosted can be, at no personal cost. Many millions of us have had COVID as well, some of us more than once. So again I ask: what “science” establishes the incremental benefit of mask wearing among the well and truly immunized? Is that incremental benefit greater, or lesser, than the inconvenience of mask replacement in between successive almonds?

I am not jesting here. Everything in public health and medicine is, and should be, based on risk/benefit tradeoffs. In some cases- cardiogenic shock, for instance- extremely high-risk interventions (e.g., inserting a flow assist device into the left ventricular outflow tract) are fully warranted, because the alternative is almost certain death. At the other extreme, almost any risk is unacceptable when benefit is vanishingly small. The “risk” of mask mandates lies not in the mask, however annoying that may be between bites and sips; but in the mandate. Let me make that clearer.

Maybe masks do reduce COVID risk incrementally even among the well and truly immunized. In that vein, I am quite certain that wearing a helmet while driving your car would incrementally reduce your risk of head injury even with steel safety cage, air bags, and seat belt; it would do the same for your passengers. Should it be mandated? So, too, a life jacket at the beach or pool, no matter your ability to swim, no matter the diligence of the guards. Should that be mandated? You, and others, are potentially at greater risk of injury if you drink alcohol near water, or a camp fire, or backyard grill. Should that be outlawed?

We routinely tolerate some preventable risks in our daily routines- risks to ourselves and others- because safety, while an imperative, is not the only imperative. We care about living as well as life; we care about choice, liberty, and autonomy. If there is a valid reason why that should pertain to every source of risk except COVID, I have yet to hear it.

We do have simulation models indicating a benefit of masking until certain levels of vaccination are achieved. However, we now know those levels of vaccination will never be achieved, in part because overblown claims of “science” squandered the moral authority required to lead us there. We also have evidence that masks appear to be less effective against the current viral strains, attenuating the incremental benefit, whatever it was.

Recall that the primary benefit of masking is to protect not yourself, but others. We doctors wear masks to protect our patients. Those now decrying the unmasking at altitude are not worried about the others who are cheering it; they deplore those others as “covidiots” on social media. They are worried about themselves. 

Which leads back to: any American worried about COVID exposure now has the option of being fully vaccinated and boosted at no personal cost. The incremental benefit of others masking in that scenario is not established, to say nothing of the incremental benefit in a scrupulously air-filtered airplane cabin, and to say nothing as well about the obligatory, intermittent unmasking on longer flights to accommodate bites of this, or sips of that. Is a mandate for the mask-on, mask-off, mask-on, mask-off that eating and drinking require of any established value, or is it all a bow to pandemic theater?

If that unestablished value is essential to your peace of mind, despite vaccines, boosters, and filtered air – then unless you have no choice, you should probably choose not to fly.

If masking now is still a good idea, when will it stop being a good idea? Will the reversion to mask-free flying be appropriate based on epidemiology, ideology, or perhaps psychology- when the fear of COVID abates? Would mask use rightly revert to personal choice when a majority of us are unafraid to go without- or when the very last, anxious holdout is? Will it only be appropriate when the risk of COVID transmission is zero- which, of course, is never- as it is never for a whole host of other pathogens that were out there all along? If masking is a good idea because risk is not otherwise zero, should we mandate helmets and life vests, too, to be on the safe side?

Those citing the toll of COVID are not wrong. Those contending that claims of science should actually be supported by science are not wrong. Those arguing that we should care about, and sometimes for, one another’s well-being are not wrong. Those asserting that mandates where autonomy used to be should be plied with extreme caution are not wrong. Opinions about the limited legal authority of the CDC may not be wrong, but neither are opinions about the far greater moral authority that once rendered such stipulations moot.

My personal inclinations here, in case you couldn’t tell, lie along a middle path very much less traveled. My point is that the current drama unmasks, more than anything, our native biases; our current penchant for discord; our predilection to judge first, consider after (if ever); and the liabilities of invoking science where data are few and dogma prowls. 

The pandemic that might have brought us together in common cause has instead unmasked the extremist tendencies in our nature, amplified into every manner of peril by Internet echo chambers. A deep breath of reflection and reconsideration- masked or unmasked- seems warranted now to concede uncertainties in all directions, and convene some better angels while there is harm left to prevent.

You breathe; I’ll go get the almonds.

-fin

Dr. David L. Katz     is a board-certified specialist in Preventive Medicine/Public Health and at this point, a certified COVID curmudgeon.

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