Republic of Face Masks
For the past three consecutive days, Taiwan has reported zero new cases of the coronavirus! Notably, this has been accomplished without resorting to a national lockdown. Throughout the entire crisis, people have continued to go to work, attend school, eat at restaurants, and shop in stores. Without significant disruption to lives and livelihoods, the spread of the coronavirus has essentially been stopped (for now) in this country of 23 million.
Of the 429 total cases of COVID-19 in Taiwan so far, only 55 are considered to be local transmissions (usually family members or colleagues of people who have travelled abroad). Despite its proximity to China, how did Taiwan keep the imported cases from sparking a larger community outbreak?
Taiwan’s government response has been comprehensive and multifaceted (including airport screening, aggressive contact tracing, home quarantine process, distribution of thermometers, informative daily CDC briefings, etc), but I wanted to talk specifically about the outsized role of face masks in Taiwan’s response to COVID-19.
SARS made face masks normal
To understand the attitudes in Taiwan toward face masks, it’s important to refer to another coronavirus epidemic: In 2003, Severe Acute Respiratory Syndrome (SARS) struck Taiwan and other parts of Asia. For several months, people were in a state of high alert, constantly wearing face masks (in schools, in public places, etc) as a way to protect themselves from the virus. Thankfully, the number of deaths was limited due to all the measures taken (helped by the fact that SARS is only contagious when a fever is present), but there was lasting impact from the extended crisis: it made people very alert to the dangers of infectious diseases, and it normalized the wearing of face masks for disease prevention.
While people on scooters had previously worn cloth masks to filter out pollution, the wearing of surgical masks became a regular sight on the street and in the subway. Surgical masks and other types of face masks were routinely sold in convenience stores in Taiwan, and people would wear them to prevent the spread of disease.
COVID-19 = SARS 2
When COVID-19 (or “Wuhan pneumonia” as it was known then) exploded in Wuhan and spread throughout China, people in Taiwan immediately recognized the danger of this SARS-like disease! (In fact the official name of the virus for COVID-19 is SARS-CoV-2, meaning “SARS Coronavirus 2.”) There was great concern that the large numbers of Taiwanese coming back to Taiwan from China for the Lunar New Year’s holidays might bring the virus with them. This had to be taken seriously! Based on lessons learned from the SARS experience, the government quickly put into place various measures such as a centralized command center, airport screening, home quarantines and contract tracing.
As for ordinary citizens, they also applied the lessons they learned from SARS and immediately sought out face masks — in particular, surgical masks which offer more protection against smaller droplets. Supplies of surgical masks quickly sold out in stores, and the government acted quickly to meet this demand by working with private companies to launch an emergency team to build new machines and set up manufacturing lines in record time, tripling the nation’s production capacity in 6 weeks (rather than the 6 months it would normally take).
A rationing system was set up so that everyone in the country could have equal access to a quota of surgical masks — initially 2 masks per week, which has since increased to 4.5 masks per week (i. e., 9 per 2 weeks) as production has increased. (After the production amount exceeded domestic consumption, Taiwan began to donate surgical masks to support medical staff in other countries.)
There is surprising consensus in Taiwan regarding face masks as a way to protect against respiratory disease. Even the political opposition hasn’t questioned the effort to give everyone access to surgical masks; in fact, the criticism of the government has focused on people not getting enough masks (e.g. the weekly quota was too low, people were waiting too long in queues, the online order system wasn’t easy enough to use). Long before there was an official rule making it mandatory to wear face masks on subways and buses, most people were already doing so on their own.
WHO knows?
In contrast to the popular faith in face masks in Taiwan (and some other parts of Asia), the official guidance regarding face masks has been very different elsewhere. In particular, the WHO has insisted and continues to insist that there is no need for healthy people to wear face masks. The US Surgeon General initially said that face masks “are not effective in preventing the general public from catching coronavirus.” The US CDC advised against wearing face masks before finally changing their recommendation on April 3rd, after the number of COVID-19 cases had already skyrocketed.
One apparent reasoning for these recommendations against face masks was that it was thought that droplets would drop quickly, so there was not a danger of breathing in the droplets as long you maintain enough “social distance” from others. The droplets would drop quickly onto surfaces, so it was important to avoid touching surfaces and wash hands.
But recent studies show that small droplets containing coronavirus can stay in the air longer than previously expected. Face masks can provide protection against airborne droplets containing the virus.
Another objection has been that people do not know how to wear masks properly, but the experience in Taiwan shows that a large population can learn how to wear surgical masks safely and effectively. Another motivation for this advisory against face masks may have been the desire to preserve surgical masks and other Personal Protective Equipment (PPE) for medical professionals. But cloth masks do provide a medium-high degree of protection against airborne diseases, and countries can both prioritize PPE for hospitals and advise citizens to wear cloth masks, bandanas or other face coverings.
If face masks do offer protection to the wearer (when used in conjunction with other recommended techniques such social distancing and hand-washing), then people should be encouraged to protect themselves. The recommendation that only sick people should wear face masks is akin to saying, “Only wear a safety belt if you are drunk. Sober people don’t need safety belts.” If there are drunk people on the road causing accidents, it’s useful for sober people to wear safety belts to protect themselves. (Also, drunk people shouldn’t be on the road in the first place…)
In addition, when people wear masks to protect themselves from breathing in virus-laden droplets, an additional societal benefit is that the masks also prevent the wearer from spreading droplets. For a disease where asymptomatic people can carry and spread the virus, if everyone is wearing face masks to protect themselves, it ends up protecting everyone else too!
Face Masks FTW
As countries start looking at life after lockdown, it’s worth taking a look at examples of countries have had some success in controlling coronavirus. Places where face masks are common (such as Taiwan, Hong Kong, Vietnam, South Korea and Japan) have seen less growth in COVID-19 cases than non-mask-wearing countries.
It has also been possible to apply this face mask strategy in non-Asian countries without a history of wearing face masks: the Czech Republic promoted mandatory face masks and led a nationwide effort to produce handmade masks as a key part of their strategy in combating the coronavirus. The country has seen far fewer cases than its neighbors and has lifted its lockdown already.
The social and economic impact of lockdowns have been devastating in many countries, so after the lockdowns are lifted, it would be highly desirable to avoid another explosion in cases that would require another lockdown. As described in The Hammer and the Dance, after applying a drastic lockdown (“the hammer”) to bring down the cases to a more manageable levels, it becomes possible to apply other techniques (“the dance”) to control the coronavirus while still allowing people to go to work, school, and take part in other activities. These techniques include social distancing, hand washing, temperature taking, testing, contact tracing, isolation, quarantine, etc… and universal face masks should be a critical component of these efforts. Face masks for the world!
Taiwan has been able to keep the incoming sparks from turning into a fire. The incoming cases that were not caught through airport screening or quarantines did not end up causing any clusters that grew uncontrollably. People in Taiwan very much believe that face masks have been an important part of their success in controlling the spread of the coronavirus. It may be worth listening to them.
References:
- “Taiwan’s Response to Covid-19 Is a Lesson in Managing Risk.” The News Lens. https://international.thenewslens.com/article/134301
- “Response to COVID-19 in Taiwan. Big Data Analytics, New Technology, and Proactive Testing.” Journal of the American Medical Association (JAMA). https://jamanetwork.com/journals/jama/fullarticle/2762689
- “Taiwan’s ‘hidden champions’ help coronavirus fightback.” Nikkei Asian Review. https://asia.nikkei.com/Business/Industry-in-focus/Taiwan-s-hidden-champions-help-coronavirus-fightback
- “Turbulent Gas Clouds and Respiratory Pathogen Emissions. Potential Implications for Reducing Transmission of COVID-19.” Journal of the American Medical Association (JAMA). https://jamanetwork.com/journals/jama/fullarticle/2763852
- “How to Significantly Slow Coronavirus? #Masks4All” from the Minister of Health of the Czech Republic. https://www.youtube.com/watch?v=jZtEX2-n2Hc
- #WearAFuckingMask https://wearafuckingmask.com/
- #Masks4All https://masks4all.co/
Essays by Tomas Pueyo:
- “Coronavirus: The Hammer and the Dance.” https://medium.com/@tomaspueyo/coronavirus-the-hammer-and-the-dance-be9337092b56
- “Coronavirus: Learning How to Dance.” https://medium.com/@tomaspueyo/coronavirus-learning-how-to-dance-b8420170203e
- “Coronavirus: The Basic Steps Everyone Can Follow.” https://medium.com/@tomaspueyo/coronavirus-the-basic-dance-steps-everybody-can-follow-b3d216daa343
