Face masks are taking over Europe. In Italy, they are mandatory on public transport, in shops, and in every situation (indoors or outdoors) where social distancing cannot be observed; in Spain, all people over six are required to wear a face mask unless they can keep a 1.5-metre distance from each other; in Germany, face masks are compulsory in all public spaces, with the state of Thuringia requiring that workers wear them in the office, too.
Once again during the coronavirus crisis, Britain is an outlier. As the lockdown is eased and biblical crowds pour onto the country’s beaches, face coverings – that is: any piece of fabric shielding one’s mouth and nose – are only compulsory on public transport in England, Scotland, and merely recommended in Wales and Northern Ireland. Nowhere in the UK are face coverings mandatory in shops or in other settings where social distancing is arduous – although they are recommended. Is this another British exceptionalism-inspired catastrophe waiting to happen? Or is Britain getting this right?
The British Medical Association, the UK’s main professional association for doctors, has unequivocally called for face coverings to be made mandatory in all indoor settings.
The chair of the association’s council, doctor Chaand Nagpaul, says that the UK’s face coverings strategy is “out of step with other leading nations, including those in East Asia, where they have experienced the pandemic at an earlier stage, and where widespread use of face masks was part of their strategy to control the spread.”
Nagpaul thinks that the UK government – and Scotland’s devolved administration – are “lacking is a policy that is consistent” on face coverings.
“It doesn't make sense to say that the virus is a risk to people in public transport but it's not a risk for people who are in other crowded environments. It's the same virus, it has the same infectivity,” he says. He contrasts that with Spain’s much more resolute action around face masks – which the government distributed to the population free of charge in May.
Around the world, messaging around the usefulness of face masks and face coverings after the global explosion of the Covid-19 crisis has changed over time. In the early phases of the outbreak, the usage of masks was discouraged in some western countries – notably the United States – on the grounds that the evidence for their effectiveness was not strong, and that a rush on medical masks could create shortages of essential protective equipment for the medical personnel.
More recently, though, several public health agencies have started encouraging the usage of non-medical face coverings not as a protection, but rather as a means of reducing the spread of virus-laden droplets from asymptomatic patients in close-quarters contexts – such as in shops or in mass gatherings. The World Health Organisation (WHO) updated its advice on face masks on June 5, and Nagpaul points out that both the US Centre for Disease Control and Prevention and its European Union counterpart ECDC have endorsed the use of face masks in the general community.
Still, both the WHO and the ECDC are rather cautious in their recommendations. The WHO advice acknowledges that there’s no “high-quality or direct scientific evidence” proving face masks’ effectiveness, but that “a growing compendium of observational evidence” suggests that governments should “encourage” mask-wearing among the community; the advice stops short of suggesting that masks or coverings be made mandatory. The ECDC is similarly aloof, saying that the use of face masks in shops and other indoor spaces “could be considered”.
The fact is that – while more and more studies are being published that suggest face masks could play a significant role in confronting the pandemic – there is no definitive clincher about face coverings’ efficacy or lack thereof. “The evidence is not strong – it's quite sparse,” says Susan Michie, a professor of health psychology at the University College London and a member of the Scientific Pandemic Influenza Group on Behaviours – an expert group advising the UK’s Scientific Advisory Group for Emergencies (Sage).
In May, Michie coauthored a paper reviewing ten studies and 11 randomised control trials on the effectiveness of face masks at reducing viral respiratory diseases including some coronaviruses, but not the coronavirus causing Covid-19. “If you take everything together, on the basis of what evidence we have about wearing masks in community settings, the case for and against [face masks] are about equipoise,” she says. Face masks have a clear utility in medical settings, where the risk of contagion is high, but when it comes to the general public, there are other factors to take into account.
“People tend to take their masks on and off at regular intervals, moving them on their chins, or on their foreheads,” Michie says. “Now, masks are very good ways of gathering viruses, they have quite a nice density, which then spread over your face [when you move the mask]. You touch your face and then touch other surfaces, and you're setting up a new transmission route for the virus.”
Another problem, Michie explains, is that face masks can give some people a false sense of security, leading them to be more cavalier about social distancing and hand hygiene practices. Others argue that, on the contrary, face masks and face coverings can act as constant reminders of the risk of contagion. “The wearing of seat belts has actually been accompanied by people driving more carefully,” Nagpaul says.
Nagpaul argues that the UK government has not invested as much in public messaging around the usage of face coverings, as it has, for instance, in publicity around social distancing and hand-washing. To be fair, the government’s website features a page detailing how to fashion a homemade face covering and how to wear it, but it is true that there has been no catchy slogan or publicity offensive on the government’s part. (Googling “Boris Johnson face mask” returns a long row of carnival disguises, but not a single picture of the prime minister leading by example and covering his face.)
Allyson Pollock, a professor of Public Health at Newcastle University and a member of the Independent Sage, an independent group of experts publishing advice about the Covid-19 pandemic, says that face coverings should only be promoted as “part of a package of measures, including social distancing and hand hygiene. Face coverings’ value is very weak, not strong.”
“If you are using a face covering, that should be only in conjunction with strict hand hygiene, they’re not much good if people constantly pull them on and off.”
Michie says that, on balance, the evidence is against wearing face masks when “people are just out and about in their everyday life, on the streets, and in parks”. It is, on the other hand, a good idea to wear masks on trains, buses, or taxis, while there’s no clear-cut approach when it comes to shops. “Shops are very different: some shops are very large, very open spaces, whereas other shops are small,” Michie says. “The more you have a small enclosed space with poor ventilation, and with high density people, the more that a mask would be warranted.”
The UK government itself did not respond to several direct queries about why it did not make face coverings compulsory in settings other than public transport. “We continue to advise individuals to wear face coverings in enclosed public spaces where social distancing is not possible,” a spokesperson for the Department for Health and Social Care says.
A statement on the website of the Welsh government, addressing the frequently asked question of why face coverings are not compulsory on Welsh public transport, reads that “the clear advice from the WHO and our own technical advisory group is that we should recommend, rather than mandate, the use of three-layer face coverings on worn on public transport.”
“We have also considered how realistic or fair it would be for public transport workers to enforce a mandatory approach and feel it would not be practical.”
Gian Volpicelli is WIRED's politics editor. He tweets from @Gmvolpi
This article was originally published by WIRED UK
