The Tank and the Motorcycle

The Incredible Importance of Wearing Masks

Reality Check:

Two weeks ago was the last time I wrote. Globally there were 661,394 confirmed coronavirus cases and 30,671 deaths. Today there are 1,850,345 cases and 114,053 deaths.

Two weeks ago in the U.S., there were 122,273 confirmed cases and 2,047 deaths. Today there are 558,897 cases and 21,991 deaths.
https://www.worldometers.info/coronavirus/#countries

I’m writing this edition as an essay, rather than my typical newsletter format. I wanted to address some questions that have obsessed me for the past week, about the U.S. change of policy on face masks, whether they help slow the spread of coronavirus, and how that might change our culture.

What I learned was stunning.

This past week may be the hardest I have ever worked. Based on what I have learned about the role of face masks in preventing coronavirus spread, in the last week, through our company Saturn Five, we have started a wholesale business to supply masks to hospitals and health systems. That business is called Saturn Five Health and we have already sold thousands and thousands of units to healthcare providers in the U.S. Our mission is to care for those who care for us — the doctors and nurses on the front lines — by getting their organizations needed N95 masks, gowns, gloves and even ventilators. If you know a health care provider in need of large amounts of PPE, direct them to us to help.

In the last week we also started a social enterprise to offer a buy one, give one face mask program. It is called face2facemasks.org. You can buy masks for yourself and your family. For every mask you buy, we will give a mask to a homeless shelter serving people who have no ability to social isolate and “stay home” and have no ability to purchase masks for themselves. I’ll write more about that at the end, but I unashamedly ask you to buy masks and give masks through our program. 100% of profits go to the American Hospital Association’s 100 Million Mask Challenge, getting donated PPE to the hospitals with the most critical needs.

Now, on to the content. I’ve read more than one-hundred fifty articles on masks in the past week and am distilling what I learned there for you.

Here is what you will take away from reading:

Eleven Reasons Everyone Should Wear A Mask

1. Because this virus is airborne (and what that means)…
2. …and Masks work against airborne diseases like SARS
3. Because Covid-19 spreads asymptomatically
4. This should be common sense
5. The mechanics of how transmission happens and is blocked by a mask
6. How “‘perfect” is the enemy of the good
7. Masks disrupt the three pathways of transmission
8. Studies have proven masks to slow disease growth
9. Countries that wear masks fight Covid-19 more effectively than countries that don’t
10. Masks create the right kind of social signalling
11. Masks are our best hope to move past lockdown into freedom

Why the government initially discouraged us from wearing masks

1. The terrible decision to downplay the severity
2. The reality of being underprepared and ill-equipped
3. Why we have a mask shortage
4. How our post-truth culture is causing faith in institutions to crumble

The Tank, the Motorcycle, and the car — What kind of mask should you wear?

• Why you shouldn’t wear an N95 Mask
• Why you shouldn’t rely on a t-shirt or a handkerchief
• Why a simple surgical mask is your best bet

Wearing a mask is a culture-changing decision and could save all of us

• Some countries have worn masks for years (and why the West hasn’t)
• Some thoughts on identity and freedom
• The era of the handshake is over

What you can do TODAY to help

Read widely. Read wisely.

Max

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It is time we all wear masks.

Up until a week ago Friday, the Centers for Disease Control recommended that Americans need not wear masks to prevent the spread of Covid-19. Then, they suddenly changed their minds.

Why?

In the middle of the biggest public health emergency our generation has ever faced, did our leading experts have it wrong? What I’ve read in the past week has convinced me that our initial thinking about masks may have caused irreparable harm and thousands more deaths.

I want to share what I’ve learned about the importance of masks, the challenges we face in changing our habits, and what we can do now to turn things around.

Why Everyone Should Wear A Face Mask

1. Coronavirus is airborne in the way that matters

Initially, the main guidance we got about the disease was to wash our hands and to social distance because we knew the virus traveled mainly on droplets of liquid and didn’t remain in the air. It lives on surfaces for a while we learned, so we know we better keep the counters clean. But we may have underestimated the risk of the virus in the air. In The Atlantic, Ed Yong had a great piece to explain this:

“Confusingly, in public-health circles, the word airborne has a technical meaning that’s not just “carried through the air.” When people are infected with respiratory viruses, they emit viral particles whenever they talk, breathe, cough, or sneeze. These particles are encased in globs of mucus, saliva, and water. Bigger globs fall faster than they evaporate, so they splash down nearby — these are traditionally called “droplets.” Smaller globs evaporate faster than they fall, leaving dried-out viruses that linger in the air and drift farther afield — these are called “aerosols.” When researchers say a virus is “airborne,” like measles or chickenpox, they mean that it moves as aerosols. When the World Health Organization asserts that the new coronavirus is “NOT airborne,” it’s claiming that the virus instead spreads primarily through the close-splashing droplets, which either land directly on people’s faces or are carried to their faces by unwashed, contaminated hands…

“…The question, then, isn’t whether the coronavirus is “airborne” in the tediously academic way the word has been defined. As the journalist Roxanne Khamsi puts it, the virus is “definitely borne by air.” The better questions are: How far does the virus move? And is it stable and concentrated enough at the end of its journey to harm someone’s health?

In the New York Times, microbiologist and Pulitzer-prize winner Dr. Siddhartha Mukherjee agreed, “I think the vast amount of data would suggest that the coronavirus is an airborne infection carried by respiratory droplets, and it also can be passed on by direct contact.”

2. The good news is masks are pretty effective at blocking airborne pathogens

In “What’s the evidence on face masks?” Dr. Adrien Burch, who holds a P.h.D. in microbiology from Cal Berkeley, reports that the single most effective intervention for fighting SARS was not hand washing but wearing a face mask:

“Although Covid-19 is a novel disease, it is caused by the SARS-CoV-2 virus, which is closely related to the virus that caused the SARS epidemic 17 years ago. However, since Covid-19’s true genetic identity was not widely publicized until recently, influenza research probably shaped doctors’ initial opinions about face masks instead. What does the actual science say about SARS?

“According to research on the SARS epidemic, face masks were the most consistently effective intervention for reducing the contraction and spread of SARS. In a Cochrane Review on the subject, six out of seven studies showed that face masks (surgical and N95) offered significant protection against SARS. Hand washing was also very effective, supported by four out of seven studies in a multivariate analysis.”

Others are less conclusive. From the Wall Street Journal, “Is it Time To Wear A Face Mask?”:

Sten Vermund, dean of the Yale School of Public Health, says a 2005 study found that face masks reduce respiratory virus transmission by about 10%.

That doesn’t sound impressive to me, but the article continues, “Though modest, a 10% effect could be huge, says Dr. Vermund. ‘I don’t scoff at small effects applied to millions and millions of people,’ he says.”

3. Covid-19 spreads asymptomatically

According to the BBC the number of Chinese Covid-19 cases may have been underreported because people didn’t exhibit symptoms. That is good news because it may mean that the mortality rate is much lower than the official rate when compared with confirmed cases. On the other hand, it means that the virus may spread most through people who act and feel healthy.

“A recently published study of cases in China found that “undocumented cases of infection”, or those with either mild or no symptoms, were significantly contagious and could have been responsible for nearly 80% of positive virus cases.”

NPR reports that we should wear masks because we’re contagious before we we start feeling sick:

“The primary benefit of covering your nose and mouth is that you protect others. While there is still much to be learned about the novel coronavirus, it appears that many people who are infected are shedding the virus — through coughs, sneezes and other respiratory droplets — for 48 hours before they start feeling sick. And others who have the virus — up to 25%, according to Centers for Disease Control and Prevention Director Dr. Robert Redfield — may never feel symptoms but may still play a role in transmitting it.”

Four physicians writing an op-ed for the New York Times reported that 25–50% of all Covid-19 cases may be asymptomatic. Their conclusion? That because of those rates it would be best if every wears a mask when in public, to support others.

In other words, the most generous thing you could do, and likely the most reasonable, is to assume you have Covid-19 even if you don’t have symptoms.

You should behave as if you need to protect others from catching it from you. And the best way to do that is to wear a face mask.

A letter in the medical Journal The Lancet put it bluntly, “As evidence suggests COVID-19 could be transmitted before symptom onset, community transmission might be reduced if everyone, including people who have been infected but are asymptomatic and contagious, wear face masks.”

4. This Should Be Common Sense

I admit I was kind of surprised when I first learned that the Surgeon General had encouraged Americans not to buy masks. I wasn’t the only one.

“It’s just common sense that a mechanical barrier must do something,” said Annalies Wilder-Smith, a professor of emerging infectious diseases at the London School of Hygiene and Tropical Medicine, who recommends using masks to prevent transmission in the home.

As the doctors in the op-ed, I mentioned earlier put it,

“Even if masks don’t completely protect each individual, they could considerably reduce the spread of the virus. Even if the coverings only reduced transmission to and from each wearer by half, that would reduce the chance of spread by 75 percent. So face coverings could reduce the exponential growth of new infections and avert disaster in America’s hot spots.”

When Dr. Siddhartha Mukherjee was asked by the New York Times if everyone should wear a mask, he replied;

“I think so. I think the issue is there are various kinds of masks. There are the expensive and highly efficient N95 respirators. Doctors have to get fitted for them. They are hard to get. Not everyone should be wearing those, and no one should be hoarding those. Those should be reserved for medical personnel. But then there is a simpler, so-called surgical mask, which is just a filter across your face, which prevents you from secreting respiratory droplets, and prevents others from getting respiratory droplets from you. These are cheap. In the hospital, we used to just use one and throw it away. But under these circumstances, we need a good decontamination protocol. So if you are talking about the simpler ones, then yes. Everyone should be wearing them, because the risk is low, and the return may be high.”

5. The mechanics of transmission

In a terrific article, Sui Huang from the Institute of Systems Biology, explains how transmission occurs through sneezing or coughing,

“How viruses that cause airborne diseases are carried by droplets from person to person is a complicated, understudied matter. Droplets can (for this discussion) be crudely divided in two large categories based on size (FIG. 2):

FIGURE 2. Droplet larger than aerosols, when exhaled (at velocity of <1m/s), evaporate or fall to the ground less than 1.5 m away. When expelled at high velocity through coughing or sneezing, especially larger droplets (> 0.1 mm), can be carried by the jet more than 2m or 6m, respectively, away.

(a) Droplets below a diameter of 10 um (micrometer), the upper size limit for the definition of ‘aerosol’ (particles so light as to be able to float in the air). For brevity, let us call this category “aerosols”. These small aerosols are carried by ventilation or by winds and thus can travel across rooms. What makes N95 facial masks different from the surgical masks is that the former are designed (as per regulatory requirement) to stop aerosols: they have to filter out 95% of droplets smaller than 0.3 um.

(b) Droplets larger than 10um (micrometer), reaching 100um (0.1mm) or more. Let us call these large particles “spray droplets” here. (For a more detailed discussion, see Nicas and Jones, 2009). Of course, droplets can be even larger, up to a size visible to the naked eye in the spray generated by coughing or sneezing (0.1 mm diameter to above). Calculations by Xie et al suggest that if exhaled, the >0.1 mm droplets may evaporate or fall to a surface within 2m, depending on size, air humidity and temperature. But coughing or sneezing can shoot them like projectiles out of the mouth with a “muzzle velocity” of 50 meters/second (for sneezing) or 10 m/s (for coughing), and droplets can reach distances as far as 6m away. If so, then the much mentioned “safe distance” of 6 feet in social encounters may not suffice — except you wear a (simple) mask –more on that later.”

6. How “Perfect” is the enemy of the good

Huang makes this point to those who who pooh-pooh face masks because they aren’t 100% effective in preventing contagion through aerosols. I quote it at length below.

“Nuances do not translate well to lay people.(as well as many arm chair experts) who now, owing to message binarization, think that masks are useless.

However Huang writes that the truth is more complicated. He says we must not forget that “the partial filtering provided by surgical masks is better than nothing. In an experimental simulation of the filtering capacity of masks in 2008, van der Sande and her colleagues in the Netherlands compared three masks, (i) home-made (DYI) of tea cloth, (ii) standard surgical masks and (iii) FFP2, the European equivalent of N95 masks, with respect to their ability to stop small aerosols in the range of 0.2 to 1 um –droplets that can reach the lower lung.

“What the authors found for inward protection warrants some questioning of CDC’s message that surgical masks are “not effective”: While FFP2 (or N95) masks indeed filtered out >99% of particles (thus, reducing the aerosol load by 100-fold), the surgical masks lowered the number of aerosol droplets behind the mask still by a substantial 4-fold compared to outside of the mask.

“If all we want is to mitigate the pandemic, that is, to “flatten the curve”, how much does a 4-fold reduction of particles that reach the lungs decrease transmission from person to person? Intuition suggests that even an imperfect mask may offer some protection that is at least in the range of the recommended separation by more than 6 feet in social interactions or wasing hands or not touching your face

“Sure, surgical masks, and improperly worn N95 respirator masks, do not offer perfect protection. But if the stated goal is to “flatten” the curve (as opposed to eradication of the virus), we have to abandon the black-and-white thinking, and embrace shades of grey. We cannot any longer claim that masks “are not effective”. We cannot allow the perfect to be the enemy of the good.”

7. Masks disrupt the three pathways of contagion

Masks aid in decreasing COVID-19’s virality by three pathways, concludes MasksSaveLives:

• Decreasing virus spread by infected individuals. The mask traps virus particles on the inside, preventing the virus particles becoming airborne. Protect others.
• Decreasing new infections by uninfected individuals. The mask prevents airborne virus particles being inhaled from the outside. Protect yourself.
• Limiting hand to face contact. The mask puts a physical barrier between potentially contaminated hands and passages to one’s lungs.

Let’s focus on the hand/face contact. Two lecturers from Yale University wrote in the Boston Globe that masks are:

“the best way to enforce the “do not touch your face” mantra we are hearing about for COVID-19. The coronavirus, like all respiratory viruses, needs to enter mucous membranes in the nose, throat, and eyes to cause infection. If you can successfully block access to these critical entry points, you will avoid infection by the coronavirus, flu, and any of several hundred other respiratory viruses.

“Unfortunately, we humans are relatively unique among mammals in that we continuously touch our eyes, noses, and mouths for seemingly no reason every 2.5 minutes. This behavior is hard-wired and starts in utero. Let’s get real — we’re not going to be able to instantly stop doing something we’ve been doing our whole lives.

“So what’s the answer? Cover your face with a mask. This will deny you access to your own face and make you conscious of how often you are tempted to touch your nose and mouth.”

Masks serve as a reminder to help us remember all kinds of behaviors that will keep us safe.

“Wearing a mask is a mental reminder that things are not normal,” writes the author of Idle Words. “Just like many religions ask believers to wear a special garment to keep them mindful of their duty to God, having a mask on your face can help you remember that you are in a situation that calls for special behavior.”

In addition, “Masks are somewhat uncomfortable, a helpful feature when we’re trying to limit time spent in public places. Wearing one out in the world gives you an incentive to get your business done quickly so you can go home, scrub your hands, and paw at your naked face in voluptuous luxury.”

8. Studies show masks can slow disease growth by preventing transmission

From Idle Words: “A study published in Nature on April 3, Respiratory virus shedding in exhaled breath and efficacy of face masks, tested viral transmission by having sick and healthy people exhale through a procedure mask for half an hour. It concludes that “surgical face masks could prevent transmission of human coronaviruses and influenza viruses from symptomatic individuals.”

Vox wrote this about of the evidence for mask efficacy:

“A 2008 systematic review, published in BMJ, found medical masks halted the spread of respiratory viruses from likely infected patients. In particular, studies on the 2003 outbreak of SARS — a cousin to the coronavirus that causes Covid-19 — found that masks alone were 68 percent effective at preventing the virus. By comparison, washing hands more than 10 times a day was 55 percent effective. A combination of measures — hand-washing, masks, gloves, and gowns — was 91 percent effective.

“A 2015 review, also published in BMJ, looked at mask use among people in community settings, specifically households and colleges. Some studies produced unclear results, but the findings overall indicated that wearing a mask protected people from infections compared to not wearing a mask, especially when paired with hand-washing. A big issue was adherence; people were often bad at actually wearing masks, which, unsurprisingly, diminished their effectiveness. But if masks were used early and consistently, the authors concluded, they seemed to work.

“Other studies have produced similar results, typically finding at least some protective value from masks as long as they’re used consistently and properly.”

9. Countries that wear masks fight coronavirus more effectively than those that don’t.

Wearing a mask is standard and recommended by public officials in many Asian countries. And though the virus began in China and first spread to Asia, it is under control in China and Taiwan and South Korea where mask protocols are universal.

George Gao, director general of the Chinese Center for Disease Control and Prevention, said this in an interview with Science magazine:

“The big mistake in the US and Europe, in my opinion, is that people aren’t wearing masks. This virus is transmitted by droplets and close contact. Droplets play a very important role — you’ve got to wear a mask, because when you speak, there are always droplets coming out of your mouth. Many people have asymptomatic or presymptomatic infections. If they are wearing face masks, it can prevent droplets that carry the virus from escaping and infecting others.”

Last month, the New YorkTimes reported, “places like Hong Kong and Taiwan that jumped to action early with social distancing and universal mask wearing have the pandemic under much greater control, despite having significant travel from mainland China. Hong Kong health officials credit universal mask wearing as part of the solution and recommend universal mask wearing. In fact, Taiwan responded to the coronavirus by immediately ramping up mask production.”

There are many factors at play in a country’s rates of infection, but these charts from MasksSaveLives about face mask use and infection rates are compelling:

10. Masks Create the Right Kind of Social Signaling

I shared above a writer who compared mask wearing to head coverings in religious observence — both creating powerful reminders to the wearer that this is a special moment. It can also send a signal to others. As the authors of the Boston Globe write,

“Wearing masks is a powerful signal to others that these are not normal times, and that we all need to change our behaviors to stop a potentially devastating epidemic. Wearing a mask for the first time can be deeply uncomfortable, especially when others are not doing the same. We felt strange at first, but after a few days, we’ve become proud rather than embarrassed to wear a mask outside. If more people donned masks, it would become a social norm as well as a public health good. If we can stop handshaking to fight COVID-19, we can also end mask stigma.”

Idle Words also made a good point: If we don’t all wear masks when we feel healthy, people who feel sick but must go out for some reason might be too embarrassed to wear it.

“Universal mask use gives cover to sick people who, for whatever reason, need to be out in the world. If we only ask people to wear a mask when they have symptoms, they might as well put on a flashing neon sign that says INFECTED. Obviously, we want sick people to stay at home, but if they have to go out, they need be able to wear a mask without stigma.”

11. Masks are our best shot at freedom

Some might argue that mandatory mask-wearing restricts our freedom and so must be dismissed out of hand. I disagree. Masks are the key to our freedom in the near future. The alternative to mask use is continued lockdown and isolation. Once we have flattened the curve, we won’t all just return to normal like nothing happened. Everything will have changed. As Anthony ‘Fauci said, the era of the handshake is over. Similarly, the era of the maskless is over. Not forever. But for now. And whenever there is a recurrence.

Because face masks prevent transmission, the are the keys that will unlock our ability to return to a more normal and social life. Without them, we’d be gambling with our health. As Dr. Huang writes,

“If we are soon loosening the lockdown due to the political pressure to sustain the economy, perhaps encouraging face masks to be worn in the public would be a good compromise between total lockdown and total freedom that risks resurgence of the invisible enemy. There is now a robust scientific basis for putting an end to the officials’ anti-surgical mask hysteria and to recommend or even mandate a broad use of masks as in Asian countries that have bent the curve.”

Now, if, like me, you find this data compelling, you might ask, “Why were we discouraged from wearing face masks earlier?” It is to that question we now turn.

Why the government initially discouraged us from wearing masks

The first reason has been widely covered so I won’t spend much time on it. The administration initially dismissed the seriousness of the coronavirus threat. The president called it a Democratic hoax and treated it as something that was happening “over there” in China. Instead of preparing, we were caught flat footed. one shudders to think of the lives that might have been saved had the administration acted faster.

Even if they had acted faster, the U.S. at the time of the outbreak’s growth was underprepared and ill-equipped. As of a few weeks ago, the US was expected to need some 3.5 billion respirators to deal with the pandemic for the next year, but the Strategic National Stockpile contains just 13 million.

“In a recent survey, nearly 90% of mayors said their cities lacked sufficient supplies of masks to treat the epidemic.”

At the time people were starting to get scared and started buying up respirators from stores. In the face of the coming shortage, the Surgeon General Jerome Adams on February 29th tweeted,

“Seriously people- STOP BUYING MASKS! They are NOT effective in preventing general public from catching #Coronavirus, but if healthcare providers can’t get them to care for sick patients, it puts them and our communities at risk!”

But as Ed Yong, pointed out, the message was confusing. “If masks are limited, conserving them for the people who need them most makes sense. But that message was lost amid the confusing claim that masks somehow protect health-care workers but are useless for everyone else.”

As the masks grew harder to find, the federal government passed the buck to the states, saying, in effect, it is every man for himself, get your own PPE. Administration officials spin this as a free market approach to securing medical supplies. That spin belies the fact that the federal government just hadn’t planned well enough. They were scrambling too, igniting ewhat newspapers in Europe called The Mask Wars:

“A week ago, about 200,000 N95 masks were diverted to the US as they were being transferred between planes in Thailand, according to the Berlin authorities who said they had ordered the masks for the police force.

“Andreas Geisel, the interior minister for Berlin state, described the diversion as “an act of modern piracy” and appealed to the German government to demand Washington conform to international trading rules. “This is no way to treat trans-Atlantic partners,” Geisel said. “Even in times of global crisis there should be no wild west methods.”

The CDC came out last week with a recommendation that Americans use homemade masks like scarves and t-shirt sleeves. That wasn’t because a new study came out showing the efficacy of those means. They issued them because the realize we need to cover our mouths and noses and there haven’t been enough masks for all of us. Their recommendation wasn’t a full-throated endorsement of a Lone Ranger handkerchief mask. The recommended that Americans use them “as a last resort” in “settings where face masks are not available.”

Why do we have a mask shortage?

Masks are hard to make. They require specialized equipment to meet stringent regulatory standards. So we didn’t have a lot of suppliers to begin with. The largest maker in America was doing 250,000 per day pre-crisis (now they are trying to produce millions per day).

Most of the world’s masks are made in China. Some say they account for as much as 80% of the world’s supply. When the pandemic hit China, the country shut down exports. As Vox explains, the “supply chain wasn’t prepared for a pandemic, especially one that originated in the same country where many of these masks are produced. And as the novel coronavirus spread throughout China, the country’s government bought its domestically produced masks, ensuring they weren’t exported. That’s made the gap between supply and demand in the US much larger.”

When China hit the brakes on exporting masks, the whole world suffered. But it gets worse, after the coronavirus outbreak began, China became a net importer. “China did not just stop selling masks” reports the New York Times, “It also bought up much of the rest of the world’s supply. According to official data, China imported 56 million respirators and masks in the first week after the January lockdown of the city of Wuhan, where the coronavirus emerged.” Since the start of the crisis, China imported two billion masks.

So the government discouraged us buying masks because they knew we had a supply crunch and couldn’t risk any more masks not getting to hospitals. But instead of saying that, they said masks weren’t effective. Or more exactly, they said, in the words of the Surgeon General’s tweet, that masks “are NOT effective in preventing general public from catching #Coronavirus, but if healthcare providers can’t get them to care for sick patients, it puts them and our communities at risk!” how could the masks be needed by healthcare providers and be “NOT effective” for the general public?

How our post-truth culture is causing our faith in institutions to crumble and putting us at greater risk

Unfortunately, this is the latest in a long series of official statements that are mistaken at best or intentionally misleading at first. It erodes our trust in our leaders. And makes it more difficult for us to know what, or whom, we can trust. “Fake news!” someone yells.

A few days ago Zeynep Tufecki wrote a piece in the Times that does a thorough job explaining the problems with how the government approached this (bold sections are mine):

“As the pandemic rages on, there will be many difficult messages for the public. Unfortunately, the top-down conversation around masks has become a case study in how not to communicate with the public, especially now that the traditional gatekeepers like media and health authorities have much less control. The message became counterproductive and may have encouraged even more hoarding because it seemed as though authorities were shaping the message around managing the scarcity rather than confronting the reality of the situation.

“First, many health experts, including the surgeon general of the United States, told the public simultaneously that masks weren’t necessary for protecting the general public and that health care workers needed the dwindling supply. This contradiction confuses an ordinary listener. How do these masks magically protect the wearers only and only if they work in a particular field?

“Second, there were attempts to bolster the first message, that ordinary people didn’t need masks, by telling people that masks, especially medical-grade respirator masks (such as the N95 masks), needed proper fitting and that ordinary people without such fitting wouldn’t benefit. This message was also deeply counterproductive. Many people also wash their hands wrong, but we don’t respond to that by telling them not to bother. Instead, we provide instructions; we post signs in bathrooms; we help people sing songs that time their hand-washing. Telling people they can’t possibly figure out how to wear a mask properly isn’t a winning message. Besides, when you tell people that something works only if done right, they think they will be the person who does it right, even if everyone else doesn’t.

“Third, of course masks work — maybe not perfectly and not all to the same degree, but they provide some protection. Their use has always been advised as part of the standard response to being around infected people, especially for people who may be vulnerable. World Health Organization officials wear masks during their news briefings

“Fourth, the W.H.O. and the C.D.C. told the public to wear masks if they were sick. However, there is increasing evidence of asymptomatic transmission, especially through younger people who have milder cases and don’t know they are sick but are still infectious.

“Providing top-down guidance with such obvious contradictions backfires exactly because lack of trust is what fuels hoarding and misinformation…Research shows that during disasters, people can show strikingly altruistic behavior, but interventions by authorities can backfire if they fuel mistrust or treat the public as an adversary rather than people who will step up if treated with respect. Given that even homemade masks may work better than no masks, wearing them might be something to direct people to do while they stay at home more, as we all should.

“We will no doubt face many challenges as the pandemic moves through our societies, and people will need to cooperate. The sooner we create the conditions under which such cooperation can bloom, the better off we all will be.”

The next way we can cooperate with each other and beat back this disease is by doing everything we can to prevent its spread. We’ve been isolating and washing our hands. Now we need to wear masks. But what kind should we wear?

The Tank, The Motorcycle, and the Car — What kind of mask should you wear?

When it comes to face masks, we have three main options: the medical-grade n95 mask, the common surgical mask, and now homemade masks made of common fabric. Which should you choose to wear? Let me address that by way of analogy.

Imagine you have some precious cargo you need to drive somewhere. It’s a long drive so you’ll drive fast but you’ll need to park overnight somewhere halfway. And you have to leave the cargo in your vehicle. you don’t want it falling out and you don’t want anyone getting in. I’ll give you three choices — a tank, a motorcycle, and a sedan. Which would you choose for the journey?

The tank would be ultra-safe. It’s nearly impregnable. But it is very hard to get a tank these days no matter how hard you look. And it’s pretty uncomfortable in there for making a long journey. Finally, it’s not exactly easy to drive a tank. You need to be trained.

The motorcycle would be faster and it would be a lot of fun. Imagine the wind whipping through your hair as you cruise down the road. Unfortunately a lot of people die in motorcycle accidents, and it’s not really safe to keep things on the bike.

The sedan is boring. It’s not flashy like the motorcycle or tough like the tank. it’s middle of the road, so who wants it? Well the good news is it is reasonably comfortable for the long journey. And when you need to check into the hotel for the night, you can keep your cargo locked in the trunk where, if it’s not 100% safe, it’s still a pretty good bet.

It should be obvious that the tank represents the N95 mask. It is tough — it keeps out 95% of all airborne particles 3 microns wide and larger. But it is hard to find. It is uncomfortable to wear. And you need training on how to fit it right.

The motorcycle represents the homemade or designer-made cloth mask. It can be fun and sporty and actually good looking. But it’s questionable how safe it is. Pretty easy to get on and off a motorcycle and it is pretty easy for viruses to get in and out of cloth masks

Surgical masks are the boring sedan. They aren’t cool looking. They are affordable and easier to find. But they are pretty safe. Let me say a little more about why surgical masks are the right choice for you to wear at this moment rather than cloth homemade masks or N95s.

Why you shouldn’t wear N95s

The primary reason you shouldn’t wear an N95 mask (even if you can find one) is that these are the best masks for doctors and nurses to wear who are in close contact with Covid-19 patients and they need them.There is a shortage of N95s for medical personnel and we should get all N95s we can to them instead of using in private settings. My company Saturn Five Health has secured manufacturing supply for these masks but are limiting our sales to healthcare providers and government entities.

Vox reports, “The PPE shortage is a real problem too. There are reports of doctors, nurses, and other health care workers using bandanas and scarves for masks and trash bags for gowns. Hospitals are considering do-not-resuscitate orders for dying Covid-19 patients out of fear that such intensive, close-up procedures could get doctors and nurses without PPE infected with the virus.”

A second reason not to wear an N95 is that it is overkill. As the author of Idle Words put it, wearing an N95 is “like putting on a fireman’s coat instead of wearing suntan lotion — it doesn’t do much for you, and wastes an invaluable resource that could save the life of a first responder.”

Finally, it probably won’t work for you if you haven’t been trained. “When used properly, N95 might offer more protection since it filters out smaller particles (discussed above) and also creates a tighter seal against the wearer’s face than a surgical mask. On the other hand, N95 masks are less comfortable, are frequently misused, and are taken off more often than a surgical mask.” — Better Humans.

Vox found this: “N95 respirators in theory outperform surgical masks (which are the more traditional, looser-fitting medical masks), but they’re genuinely difficult to fit and use properly — to the point that a 2016 review in CMAJ couldn’t find a difference among health care workers using N95 respirators versus surgical masks for respiratory infection, likely due to poor fitting. Given how difficult these are to use, and the extra layer of protection they can provide, experts argue these masks should, above all, be saved for health care workers.”

The Case Against Cloth Masks

Since the CDC gave the go-ahead for people to use cloth masks in situations when they couldn’t get other masks, I’ve started to see a lot of people wearing bandanas and other masks with cool designs. Let me be clear that I support cloth masks over no masks. They provide more protection than no mask at all. But i don’t support them over surgical masks. Here is why:

• Cloth masks, are much less effective than the modern alternatives, as a 2015 study in BMJ found. And they can be extra risky, since they can trap and hold virus-containing droplets that wearers can then breathe in. — Vox
• It’s worth emphasizing again that sewing your own face mask may not prevent you from acquiring coronavirus in a high-risk situation, like lingering in crowded places or continuing to meet up with friends or family who don’t already live with you. — CNET
• In one experiment, a surgical mask filtered 89 percent of viral particles from volunteers’ coughs, a tea towel blocked 72 percent, and a cotton T-shirt blocked 50 percent. — The Atlantic
• Another study determined that, while masks made out of cotton T-shirts were far less effective than manufactured surgical masks in preventing wearers from expelling droplets — Snopes
• In laboratory tests, some homemade masks did a poor job, while others rivaled the filtration of a medical mask. — New York Times

Why Surgical Masks Are Our Bet At The Moment

First of all, they perform well at keeping particulates out.

Buzzfeed: According to a 2013 study in the journal Disaster Medicine and Public Health Preparedness, fabric masks that fit snugly on the face provided three times less protection than surgical masks. “We found they are not as good as surgical masks,” Anna Davies, the lead study author, told BuzzFeed News. Davies and her colleagues found a surgical mask had about a 90% filtration efficiency for very small particles (around 2 microns). The next best materials found at home at blocking particles were vacuum cleaner bags (about 86% filtration efficiency) and tea towels (about 72% filtration efficiency), but they would be so difficult to breathe out of that they wouldn’t be suitable for a mask. Meanwhile, a cotton mix material had about 70% filtration efficiency compared to roughly 57% for a pillowcase, about 62% for linen, about 54% for silk, nearly 51% for a 100% cotton T-shirt, and nearly 49% for a scarf.

They can even rival N95 performance: “a 2016 review in CMAJ couldn’t find a difference among health care workers using N95 respirators versus surgical masks for respiratory infection, likely due to poor fitting. Given how difficult these are to use, and the extra layer of protection they can provide, experts argue these masks should, above all, be saved for health care workers.” (Vox)

I found a great article on the science of testing surgical and other masks that explains the efficacy of blocking:

“Researchers from the University of Edinburgh tested different common masks by running a diesel generator (to mimic car exhaust) and piping the exhaust through the masks. They used a particle counter to see how many particles made it through the mask. Here’s my super scientific rendering of the setup:

“One important detail: the particle counter they used measured particles as small as 0.007 microns. That’s over 10 times smaller than the coronavirus particle diameter. We’re talking about truly tiny particles here! They tested a whole range of masks, and here’s what they found:

“3M industrial filters were able to capture over 95% of particles down to 0.007 micron. Given that news outlets have claimed surgical masks can’t capture nanoparticles, it’s particularly surprising that the surgical mask was able to capture 80% of the tiny particles.”

Here is some other evidence on the effectiveness of surgical masks:

• A study published Friday in Nature showed that surgical masks of the flat, paper variety can also reduce emission of virus-carrying droplets from the nose and mouth. The study suggests that the masks “could be used by ill people to reduce onward transmission,” the authors wrote — Bloomberg.
• Although most of the studies in the Cochrane Review were on medical workers in a hospital setting, one study followed community transmission of SARS in Beijing. It found that consistently wearing a mask in public was associated with a 70% reduction in the risk of catching SARS. Additionally, the authors of the paper noted that most people in the community wore simple surgical masks, not N95 respirators. (Better Humans)
• In 2015, Abrar Ahmad Chughtai, a lecturer in international health at the University of New South Wales in Sydney, helped conduct the world’s only clinical trial on the effectiveness of cloth masks — fabric coverings which are not specialist surgical masks…The rates of all infection outcomes were consistently higher for cloth masks than for surgical masks. However, since most of the study’s control group were also wearing surgical masks, it was difficult to determine the performance of a cloth mask versus no mask at all. (South China Morning Post)
• There’s still a good case for masks, though, even if they can’t stop viruses from getting in: They can stop viruses from getting out. A new study shows that people who are infected with milder human coronaviruses release fewer viral particles when they wear surgical masks. “I’ve been slightly dismissive of masks, but I was looking at them in the wrong way,” Harvard’s Bill Hanage told me. “You’re not wearing them to stop yourself getting infected, but to stop someone else getting infected.” (The Atlantic)

Wearing a mask is a culture-changing decision and could save all of us

In China, Hong Kong, Japan and South Korea, people assume that anyone could be a virus carrier. So people wear masks not just when they are sick but anytime there is an outbreak, as a sign of social solidarity and commitment to the wellbeing of their neighbors. In Asia it is considered impolite to sneeze or cough openly so people wear masks in allergy season too. And of course, they have been shaped by history:

“The 2003 Sars virus outbreak, which affected several countries in the region, also drove home the importance of wearing masks, particularly in Hong Kong, where many died as a result of the virus.So one key difference between these societies and Western ones, is that they have experienced contagion before — and the memories are still fresh and painful…In Hong Kong, some tabloids have splashed pictures on their covers of Westerners not wearing masks and congregating in groups in the city’s nightlife district, and criticised expatriates and tourists for not taking enough precautions.” (BBC)

Ed Yong writes in The Atlantic, “Judy Yuen-man Siu, a medical anthropologist at Hong Kong Polytechnic University, told me by email that mask-wearing went from being uncommon in Hong Kong before SARS to being widely adopted afterward — as an important component of containing a viral outbreak, and as a civic duty and a signal of “support to health-care providers.” Today in Hong Kong, “if you do not use a face mask in public areas, you will be stigmatized and discriminated against, not just because people would [be] afraid of you as a potential virus-spreader, but [also because] it can mean you have low civic responsibility.

“What can be said more definitively is that mask-wearing tends to be widespread in countries that view disease outbreaks with the gravity that comes from firsthand experience with the horror of an epidemic.”

But in Asia masks aren’t just shields to protect yourself from an invisible enemy, they are also symbols. “They’re an affirmation of civic-mindedness and conscientiousness, and such symbols might be important in other parts of the world too. If widely used, masks could signal that society is taking the pandemic threat seriously. They might reduce the stigma foisted on sick people, who would no longer feel ashamed or singled out for wearing one. They could offer reassurance to people who don’t have the privilege of isolating themselves at home, and must continue to work in public spaces.” (The Atlantic)

Masks are widely used in Japan and there has been study as to why, “Some say the practice conforms with the country’s notions of cleanliness and purity. One study suggested Japanese society has lost trust in public institutions in recent decades, prompting people to become more self-protective. In another survey, Japanese people said they primarily used masks to protect themselves but that the practice also demonstrates consideration for others and a respect for etiquette. For many, masks are a kind of “safety blanket,” and the simple act of putting them on is a “risk ritual” that provides comfort and quells anxiety.” (Sapiens)

According to MasksSaveLives, “Japan has the strongest mask-wearing culture in the world and one of the lowest COVID-19 infection rates. Despite Japan’s large elderly population and early infection, the infection and death rate is one of the lowest in the world. A leading reason for this is Japan’s strong mask-wearing culture lowering the virality of COVID-19 to manageable levels. Japan has only had 1,387 infections, yet being one of the earliest countries to become infected.”

In China, mask wearing is part safety strategy and part culture. “When SARS broke out in Hong Kong, wearing a face mask expressed collectivist values, and declining to do so was met with public censure, noted sociologist Peter Baehr. By putting on a mask, “people communicated their responsibilities to the social group of which they were members,” he wrote. “By disguising an individual’s face, it gave greater salience to collective identity.” (Sapiens)

We have a much different view of masks in the West. At least we have so far. “In the West, I think we need to overcome — I wouldn’t call it a fear of the mask, but [the] stigma with a mask,” Christos Lynteris, a medical anthropologist at the University of St Andrews, in Scotland, told me. “I’ve heard people say, ‘I was carrying a mask in the airplane but I was too ashamed to wear it.’ Where does this shame come from? Is it because people will think you are a wimp? Because people will think you are ill?”

“If you wear a mask in a British supermarket, he noted, “people react strangely,” for a number of possible reasons: the association with East Asian countries, a suspicion that you’re using something that others are more in need of, a concern that you’re wearing it because you’re ill and shouldn’t be there, a conviction that you’re “unnecessarily spreading panic.” (The Atlantic)

This culture can be disorienting for Asians living in America. “I’m so tired of being harassed for wearing masks in the US. I wore a mask on my way to work today. One man walked up and coughed loudly at me. A few minutes later, another man aggressively approached me&asked: “r u a nurse?” I’m no nurse. I just know what’s coming for all of us.

— Xinyan Yu (@xinyanyu) March 18, 2020

In the West we associate an uncovered face with individual identity and with freedom. When the president announced the CDC’s support for masks he said he wouldn’t be wearing a mask and stated, “We want our country back. We’re not going to be wearing masks forever.”

As Uri Friedman pointed out in The Atlantic,

“The president seemed to be implying that a masked country couldn’t be our country — that such a sight would be alien and alarming, and thus hopefully a short-lived ordeal. It was an expression of the stigma long attached to mask-wearing in the Western world, unlike in many Asian countries, where those who don’t wear masks during public-health crises are the ones who are stigmatized. While an American might walk into a grocery store these days and view the proliferating number of masked shoppers as crushing confirmation that the apocalypse is nigh, someone in Hong Kong or South Korea might see the same scene as an uplifting indication that the community is coalescing to fend off catastrophe.” Unless we come to see the situation more like the South Koreans, we are in for trouble.

But if Anthony Fauci says the era of the handshake is “over,” then we also need to say the era of never wearing masks is over. We won’t need to wear masks always. We might get a break this summer. But if the virus resurges in the fall, our best bet to keep working and keep society moving is to avoid not only handshakes but coughs and sneezes outside of mask.

The author of idle words put it well:

“If you’ve never seen it before, a subway car full of people wearing surgical masks can be an arresting sight. In America, we still tend to associate face masks with hospitals and illness. But it only takes a short time for the practice to start feeling normal, and that’s where we want to get to in the next couple of weeks across America and Europe

“By the end of the month, wearing a face mask should be like wearing a shirt — a routine social behavior that is expected of everyone and gets you weird looks if you don’t do it.

“…The goal is not only to keep people safe, but to make it rare and weird to see anyone outside with a bare face.

“…This doesn’t mean we’ll never see a stranger’s bare face again. Once the immediate crisis is over, we can dial things down and adopt the same social norms as East Asia, where wearing a mask is an optional and unremarkable choice people make, one that tends to increase during cold and flu season, but is just a normal part of the social landscape.”

“The point of wearing a mask in public is not to protect yourself, but to protect other people from you….The job of protecting you, meanwhile, falls to everyone else! That’s why it’s so important that we adopt mask wearing as a social norm.”

In other words, we need each other. We need to take care of each other. You’re safest not when you take measures to protect yourself but when I take measures like a mask that protect you. I’m safest not when I take measures to protect myself, but when you take measures like a mask to protect me from you.

Our culture has grown increasingly isolated, independent, and lonely. We’ve given up on religion, given up social clubs. We’ve turned to entertaining ourselves to death on Netflix and to the Infinite Scroll of Instagram and Facebook. Our ethic has become to “do whatever you want so long as you don’t bother anyone else” instead of being called to service and self-sacrifice.

Doing whatever you want with fewer strings attached should make you happy right? But it hasn’t. As my friend John Kingston keeps arguing, it is leading to more drug use, depression, and suicide.

It would be an ironic twist and a small frail silver lining if this existential threat we face causes us to change and shows us how much we need each other. Our need for each other has always been there. Now we’re just seeing it in stark relief, in the eyes of the nurses commuting to hospitals to care for contagious patients, putting their own lives at risk for sake of others.

Of course it is Easter today. Those who celebrate Easter celebrate the story of one who also put himself at risk for the sake of others. I’ve been thinking about that today and I’ve been thinking about what more each of us can do.

What you can do today

As i mentioned at the top, this last week some friends and I started a social enterprise called Face2Facemasks.org. I started it because I was frustrated. Frustrated that I couldn’t help. In a natural disaster, you can go down to the local homeless shelter and serve or you can volunteer with FEMA. But with Covid-19 we’ve been told the best thing we can do to help is stay home. That’s right. But I wanted to do something more active.

I texted my friend Scott, who has imported level 1 medical supplies from China to the U.S. for years to ask if he had started selling masks. He said he had not because there had been so much fraud and so many shady outfits rushing in to make a buck. But, he said, if I needed masks, he knew several FDA-approved suppliers he could connect me to. Wow, that was easy I thought and an idea popped into my mind.

I had just read this devastating story in Wired Magazine about Covid-19’s effect on the homeless:

“Shelters are full, or closed, or too fraught with coronavirus risk to consider sleeping in. They have no access to toilets, much less toilet paper. They’ve been laid off, and there’s nobody on the street so they can’t even panhandle. Common places to find shelter and a bathroom — libraries, gyms, fast food restaurants — are closed. Soup kitchens are closing, out of food, out of workers.

“Homelessness is incompatible with health. Experts like Margot Kushel, a professor of medicine at UC San Francisco who studies homelessness, have been saying so for decades, but, in the midst of the coronavirus pandemic, it’s never been truer. “It’s a calamity. It’s our worst nightmare,” Kushel says. “It’s an enormous crisis superimposed on an existing crisis.” Unhoused people are already among the most sick in society, and now they’re physically incapable of following the [CDC’s} most basic virus-fighting directive: stay home.

“It’s nearly impossible for homeless people to maintain social distance. Their needs are met en masse. The CDC recommends 110 square feet per person for people housed together during the outbreak. Most homeless shelters simply don’t have that kind of space. “There has always been an increased risk of communicable diseases like tuberculosis, hepatitis A, and influenza,” Kushel says. Covid-19 is just the newest addition to the list. Some shelters are rearranging the furniture to house people farther apart, but those adjustments inevitably mean fewer beds, leaving more people outdoors. In Las Vegas, people are sleeping in parking lots, confined to white painted rectangles spaced six feet apart.”

I had a feeling that there must be a lot of other people like me. People who were fortunate to be healthy and financially stable but who wanted to do something to help.

So what about a buy-one, give-one program for face masks? Buy a pack of surgical masks for yourself and give a pack to shelter serving the homeless in some of the nation’s bigger cities, with 100% of profits going to donate more PPE. I worked with Scott to contract with a vetted, authorized supplier and recruited other friends to build the website. As of today, Easter, we are live.

Would you buy some masks and give some masks at face2facemasks.org? I won’t make any money off of it — we’re giving any profit away. I’m just doing this to protect my family and to practically help.

What we need is not a buy-one, give one project. What we need is a cultural change — a change where wearing a mask isn’t weird, it is a sign of social solidarity. What we need is a cultural change where we aren’t living isolated lives but are actively caring for each other. A buy-one, give-one mask won’t make that change. But it’s a start. Will you join me? Visit face2facemasks.org and throw your punch at this disease.

Read widely. Read Wisely. Wear a mask.

Max

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