The Mystery of Masks in Canada’s COVID19 response

11 min readMay 14, 2020

Masks are a mystery. There has been a lot of mixed messaging regarding masks and their effectiveness against COVID19. At first, masks disappeared off shelves, and were nowhere to be found. We were told masks are not effective, but also very effective! Now you maybe should wear a mask… but maybe not.

Do they work or not? What kind of masks should I wear? Should I wear one? Must I wear one?

Let’s address these questions, and understand the vital role masks that will play in resuming ‘normal’ society. In order to return to school, work, and leisure activities, we must have a solid plan in place to prevent recurrent waves of infection. Masks are a key factor in speeding up and sustaining a safe re-opening of the economy.

Other important and well-explored factors include continued distancing measures (especially for vulnerable groups), expansion of testing, rigorous contact tracing, and personal hygiene methods such as hand-washing. Masks are an adjunct to, and not a replacement for, these other critical interventions. Masks are not an excuse to reduce distancing.

Canada has not yet implemented universal masking policies. Source: https://masks4all.co

The confusing timeline of masks in Canada

March 28: “Most people haven’t learned how to use masks” and “there is no need to use a mask for well people.”

March 30: “Putting a mask on an asymptomatic person is not beneficial, obviously, if you’re not infected.”

April 6: “Wearing a non-medical mask is an additional measure that you can take to protect others around you.” “The science is not certain but we need to do everything that we can and it seems a sensible thing to do.” It is “reasonable” to wear a non-medical mask in public settings when physical distancing can be hard to maintain.”

April 17: New mandatory guidance: All air passengers must have a non-medical mask or face covering to cover their mouth and nose during travel, effective April 20, 2020, according to new requirements from Transport Canada. Returning travellers must wear a mask or face covering while traveling to the location of mandatory 14 day self-isolation.

The future: ???

Recommendations are constantly changing due to emerging evidence, as well as learning from other jurisdictions which have been successful in controlling COVID19 using masks as a component of public health strategy. Even the Centers for Disease Control and Prevention (CDC) in the USA reversed its masking recommendations on April 3 and began to recommend them for the general public. The COVID19 pandemic is indeed an unprecedented situation, and we must adapt quickly.

Main categories of masks:

Medical-grade: Surgical/N95 masks

Best used in high-risk medical settings for frontline healthcare professionals to reduce risk of COVID19 infection
Requires fit-testing in a controlled environment to ensure efficacy.

Non-medical: Cloth/homemade masks

Recommended for the general public to protect against asymptomatic and symptomatic transmission on a population level by catching droplets around the wearer’s mouth
Reusable & environmentally-friendly
Can be created with commonly found materials (ie. t-shirts or bandanas)
Comes in many different styles and may be fashionable
May reduce infection risk to wearer, depending on material and usage.

The evidence for masking:

Source: https://www.fast.ai/2020/04/13/masks-summary/

Masks for the public, as an intervention against COVID19, have been controversial. The evidence has been scrutinized and debated over extensively. There are unlikely to be any rigorous systematic reviews of multiple randomized controlled trials of masks specifically for COVID19 infection control anytime soon. However, the absence of evidence is not equal to evidence against.

We know that 25–50% of COVID19 cases may be asymptomatic, and that these ‘silent spreaders’ may not even know that they have the virus but can still infect other people. Asymptomatic and pre-symptomatic transmission may account for 44% of infections. Some studies even show undocumented infections may account for up to 65–80% of infections.

We know that masks are an effective intervention against other respiratory viruses. We know that masks catch droplets from the wearer’s nose and mouth, while they are breathing, speaking, coughing, or sneezing, and are an effective form of source control. My mask protects you, and your mask protects me. Research models predict that if 80% of people wore a mask, then COVID19 infections would drop to 1/12th the number of infections, compared to if nobody wore a mask.

Masks are not a perfect intervention — but neither are influenza vaccinations, and we still recommend them annually. They are cost-effective — it is estimated that each cloth mask for the public can lead to savings of $3000–6000 USD each by reducing the spread and morbidity of COVID19. Masks can help save lives and reduce the economic impact of COVID19.

What other jurisdictions have done for masks:

An ever-growing list of jurisdictions (80+ countries and 10+ US states) have implemented universal masking policies, with various degrees of stringency.

Source: https://masks4all.co/what-countries-require-masks-in-public/

Czech Republic was one of the first countries to mandate wearing a face mask when outside the home, including for nudists. They have been so successful at controlling COVID19 that mask-wearing rules will soon be slightly relaxed.

South Korean health authorities have advised everyone, regardless of symptoms, to wear masks. In Hong Kong, it is recommended “wear a surgical mask when taking public transport or staying in crowded places, or going to the hospital”. Hong Kong citizens are being provided with a cloth mask that can be washed and reused up to 60 times, which will be mailed out for free. Vietnam has been hugely successful by mandating masks and testing widely. Governments in Taiwan and South Korea have implemented mask-rationing systems to discourage hoarding and ensure adequate distribution.

Masks tend to be more culturally accepted in Asian countries, however many European countries have also been successful with implementing mask policies effectively. In Germany, masks are mandatory for public transportation and shops. In France, masks are mandatory for pupils aged 11–15, and in secondary schools and on public transportation. Austria decreased its COVID19 cases by 90% only 2 weeks after mandatory masking was implemented, amongst other public health measures. Greece has mandated masks for enclosed spaces and public transportation. The United Kingdom includes masks for the public as a key part of its reopening plan.

Even the USA is following suit: “All New Yorkers must wear face coverings when social distancing is not possible, including on public transport, in stores and on crowded sidewalks.” Other states including New Jersey, Maryland, Guam, and Puerto Rico have also mandated masks.

So what is Canada waiting for?

Recommendations for masking in Canada

As discussed above, in some other jurisdictions, masks and/or face coverings are universally mandatory in all public settings outside of one’s home. However, there are many nuances to consider, rather than simply mandating them across all settings. Masks have already been mandated for air travel by the Canadian federal government. Additional measures should be considered in order to reduce COVID19 transmission and ensure a safe re-opening of the economy.

Situations for mandatory masks or face coverings:

Mandated by government:

Public transportation (train, subway, bus, marine) for all staff and passengers (currently “strongly recommended”)
Staff in vulnerable high-risk facilities (shelters, long-term care homes, retirement homes, correctional facilities, other congregate settings)
Large medical facilities and hospitals for all staff, visitors, and patients
Students & teachers when schools reopen

Mandated by responsible business owners:

Indoor facilities for work (businesses, offices, factories, grocery stores)
Indoor facilities for leisure (gyms, malls, shops)
Indoor events (concerts, conventions, conferences)
Outpatient medical practices, clinics, pharmacies

Situations for strong recommendations of masks or face coverings:

All public gatherings not listed above
Any other situation where people cannot physically distance 2 meters apart from others, both indoors and outdoors

Exceptions to masking:

Medical conditions and/or disabilities that make it difficult to breathe with a mask, or to wear a mask
Young children, such as those under the age of two

The government must provide support such as:

Increasing PPE production/manufacturing, sourcing, & distribution (first for healthcare professionals, essential workers, and high-risk populations, then for the general public when there is adequate supply)
When shortages are resolved, masks should be made readily available in public areas (similar to hand sanitization stations)
Distributing reusable cloth masks to the public
Legislate measures to prevent hoarding, reselling, and price-gouging
If someone does not have a mask, the goal of authorities should be education and assisting them to get a mask, not to penalize them with fines, arrests, or criminal penalties
Public education campaigns*

*Public education campaigns:

To educate the public on why masks are crucial to reopening the economy
Advising the public on how to create, wear, and clean masks properly (See appendix): Mask must cover both the nose and mouth. The outside is “dirty” — do not touch it! If the mask is wet or dirty, must wash it promptly. Wash it regularly. Wash your hands before/after mask use. Limit time wearing it.

Common & valid key concerns/questions

There are some common concerns that are frequently brought up on masking discussions. These are very valid concerns that deserve attention when implementing masking recommendations and policies.

“Masks provide a false sense of security.” We must understand masks are in adjunct to (and not a replacement for) other measures to reduce risk, including frequent hand-washing and physical distancing.
“Improper use and improper donning/doffing will increase infection risk. People will touch their face more while wearing a mask.” This is why public education campaigns are needed to teach people to use masks safely and properly. People can learn to wash their hands, they can learn how to use masks. We don’t tell people to stop washing their hands if they’re not doing it properly, we teach them.
“Telling people to wear masks will reduce supplies available for healthcare professionals.” That’s why homemade and/or cloth masks are recommended for the general public, not medical-grade masks, for as long as a shortage remains.
“Masks may exacerbate social disparities and inequalities. It may be harder for some people, due to socioeconomic reasons, to have access to masks.” Education on making masks from easily accessible materials at home is needed, and the government should continue to ramp up domestic mask production in order to provide supplies for at risk groups as a priority. Masks should eventually be distributed to Canadian citizens and residents, and be readily available in essential areas, just like hand sanitizer stations or water fountains.
“Certain groups face discrimination when wearing masks.” Public education is needed to understand why masks are a positive, not a negative symbol. Additionally, if masks become more commonplace and generally accepted, then specific groups will become less likely to stand out. They may even become a sign of solidarity against racism and discrimination.
“Masks are not being disposed of properly and are polluting the environment.” There needs to be education on proper disposal of single-use masks into waste receptacles.
“Masks create plastic waste and contribute to climate change.” The public is encouraged to use reusable cloth masks which have a lower impact on the environment. Perhaps in the future, there will be biodegradable and/or recyclable versions of single-use masks also.
“Do masks give you carbon dioxide poisoning?” No, they do not. Otherwise surgeons would be in big trouble.

Mask shaming

I understand that some healthcare colleagues may feel upset when they see members of the public wearing medical-grade masks, considering the ongoing concerns regarding inadequate personal protective equipment (PPE) in healthcare settings. Unfortunately, this is a supply issue and the negativity is misdirected.

We don’t know the story behind their mask. They may be a cancer patient protecting themselves with a leftover mask from home renovations. They may be immunocompromised and using a leftover mask from their doctors appointment. Perhaps they bought a box of masks, already opened, that cannot be donated.

It’s not like we can tear the mask off their face and return it into the hospital or clinic supply! Instead, we must direct our energy towards advocating for increased PPE production and supply from the government, securing PPE from manufacturers, and educating the public on appropriate mask use.

Nobody should be shamed for wearing a mask to protect themselves and others; eventually, there may even be reverse mask shaming — shaming people for not wearing a mask.

The future of masks in Canada

Masks: yesterday — controversial, today — common sense.

If we are keen to re-opening the economy as soon as possible, we must utilize this effective and cost-effective tool to fight COVID19. Government and public health leaders should consider stronger recommendations for masking for Canadians, and provide additional public education and messaging on proper use of masks and/or face coverings. Paradoxically, masks provide freedom, because they will help reduce infection rates to a controllable level to avoid recurrent outbreaks and lockdowns. This in turn saves both lives and the economy.

Masks should no longer be a symbol of sickness, but rather a symbol of health, altruism, and respect. It represents our collective efforts to succeed in this fight, and our shared human experience. Wearing a mask will become a part of the Canadian identity — it is the polite thing to do, to demonstrate our compassion for one another.

Masks add a ‘layer of protection’ literally and figuratively, and are an adjunct to (and not a replacement for) other layers including hand-washing, widespread testing, diligent contact tracing, and sustained partial distancing measures.

Many countries have already implemented universal masking policies, with various degrees of stringency, which have likely contributed to their control over the COVID19 outbreak. It is time for Canada to also apply the “precautionary principle” & mandate masks and/or face coverings for the public, based on review of the best available evidence.

When COVID19 becomes fully controlled with an effective treatment or vaccine, perhaps we may be able to put our masks away and see each other’s smiling faces once again. But until then, masks are here to stay.

“I protect you, you protect me. We all protect society.”

#Masks4Canada #Masks4Ontario #Masks4All

Side note: Masks are underrated, but gloves are overrated. Gloves cannot be washed. Unless you are changing gloves very frequently, it is more effective to wash your hands with soap and water, or to use hand sanitizer. If you touch anything with your glove, consider it to be “dirty” — do not touch your phone or your face with it!