There certainly were a few revelations for the Australian public in 2020. The complete dominance of state Premiers and governments, and the constitutional powerlessness of the Prime Minister and federal government regarding internal border closures and health rules was one. The rise of erstwhile unknown (and unelected) public health officials to TV stardom and Rasputin-esque influence over our leaders was another. But perhaps the most curious was the public obsession with the facemask.
To say the biostatistical analysis of the data surrounding facemask use in respiratory-like illnesses (generally) and Covid-19 (specifically) is controversial is an understatement. A well-conducted randomised-controlled trial from Danish researchers found no difference in eventually testing positive to the virus whether wearing a mask or not. Epidemiological data in various geographic locations do not show a consistent trend in cases decreasing after masks are introduced: sometimes cases go up, sometimes they go down, sometimes the peak of the curve was already passed and almost invariably masks are introduced as part of a tranche of other measures making it statistically impossible to prove which had the greatest influence.
Observational data (individual studies and meta-analyses) sometimes support and sometimes oppose the usefulness of facemasks, with cloth masks in community settings having much less support than surgical masks in medical settings. It is a wild leap to jump from laboratory experiments with perfect mask use (a fresh, clean, surgical mask; never touched; not removed and replaced etc.) to “real-life” use which often involves unclean cloth masks, single-use masks used many times, and/or multiple episodes of touching and removing masks over various periods of time. Some researchers have even drawn conclusions for mask effectiveness from simulations in hamsters: show me the hamster that has popped down the street for a coffee with its hamster friends, removed the mask to drink, touched it many times before replacing it and then the real-world conclusions may be plausible.
The only thing clear about the science is that it is not clear: and this is how science is meant to be. Science evolves, new facts emerge, different analyses of data are possible and debate is essential. Science should never be preceded with “the” (usually with a capital T).
It is likely that facemasks play a role when community transmission is high and it is likely that the magnitude of this role has been vastly overstated by sections of the media. It is likely that facemasks play a limited (or no) role when community transmission is low or zero. It is also likely that the use of facemasks on children in Australian schools causes more harm than good (if, indeed, any good they cause at all).
There is increasing evidence that young children play an almost negligible role in transmission of coronavirus, and thankfully those under the age of 12 have been excluded from various mask mandates. The evidence in teenagers is less clear but there are no data to suggest that Australian schools have played a significant role in community transmission. It is hypothetically possible that they might, if community transmission was higher, but we then delve into the rightly criticised world of epidemiological modelling which has lacked transparency and often plausibility.
The medical principle of “primum non nocere” or “first do no harm” is an exceedingly important one.
Even the most ardent mask supporter, cherry-picking the most favourable observational data, could not possibly argue that masks are a healthy item of raiment outside of a respiratory pandemic. They become moist and dirty with prolonged use and are almost impossible not to touch and adjust unless you are very accustomed to them. They are uncomfortable to many and cause skin irritation. They probably increase the proportion of inhaled carbon dioxide per breath and can contribute to breathlessness in some. They decrease peripheral vision, especially downwards and present a falls-risk in the elderly.
Most importantly, children respond to facial expression from the lower half of the face. This is important in gauging emotional content and learning to form a mature emotional response in the formative years: the younger the child the more crucial these interactions become but they remain so in the teenage years. Finally, the adolescent psyche can sometimes be fragile and is certainly evolving and malleable. Learning to see one’s fellow humans as vectors of disease rather than colleagues and friends, and having fear of illness constantly instilled may very well have serious long-term ramifications that have not even been considered in this generation.
Short of another wave of high community transmission, there is no compelling reason for children to being wearing facemasks at school. Even if there was another outbreak, it should be remembered that these things are not an epidemiological version of the Harry Potter Cloak of Invisibility. It’s not as simple as “wear one and you are safe, don’t wear one and you are a public menace” and it’s a blight on the medical community that this is how the health message has been received by many.
Unmask the kids, get on with the more important elements of the broader health response, and let them have some semblance of normality in 2021.
Dr Thomas Cade is a specialist obstetrician/gynaecologist with a research doctorate in public health policy and a masters in biostatistics.
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