Dr. Lawrence I. BonchekSuimmer  2021 - Vol. 16, No. 2

To Mask or Not to Mask:
That is the Question

Lawrence I. Bonchek, MD, FACS, FACC


When COVID-19 struck, America embarked on a grand scientific experiment, testing whether our loosely regulated, essentially non-governmental health care system could recognize and cope with a massive pandemic. It did so in a characteristically American way, i.e. inconsistently at first, depending on where you lived, and with the sometimes grudging acknowledgment and cooperation of government and the private sector.

In the process we used daring new technology to develop mRNA vaccines in record time; instituted (after some false starts and an election) comprehensive public health measures such as mask wearing and “social distancing” (while incidentally creating that appealing label for the previously impolite practice of avoiding others); and organized (also after some false starts and an election) mass vaccinations on a national scale.

Meanwhile, health care systems and their front line workers nationwide confronted a crushing load of acutely ill patients. In a display of dedication by health care workers that reminds us of Winston Churchill’s “their finest hour,” the front line bent but it mostly held and did not break. Eventually, the health care system enabled us to reach a goal that even the most mathematically disinterested Americans learned to understand – the flattened curve.

Now, in another newly familiar metaphor, we seem to have turned the elusive “corner” on COVID-19, with rising vaccinations and falling death rates. Such a favorable accomplishment ahead of schedule seems to be the result of good science, good policies, and clear communication from scientists in the federal government. At long last, after near chaos last year, there is a national plan for vaccine distribution, and workable logistics for getting shots in arms. As I write this in mid-May 2021, more than one-third of the population has been fully vaccinated, and just over one-half has gotten at least a first shot.

Nevertheless, every day in May still brings almost 30,000 new cases and 600 new deaths, and too many people remain reluctant to be vaccinated. Even if this disease can no longer surprise us because we know it’s unpredictable, the advice we receive about it can still seem inconsistent and confusing.

On Tuesday, May 11, 2021, CDC Director Rochelle Walensky told a Senate health committee “we must…maintain public health measures we know will prevent the spread of this virus: mask hygiene, hand hygiene, and physical distancing.” But she had already decided to approve a change in the CDC’s guidance on those practices, and two days later, in revised guidelines that have been called “good policy, badly communicated,” the CDC announced that immunized people no longer need masks in most situations. Though data-driven, this abrupt about-face was greeted with dismay by many scientists, and with consternation by governors and mayors unable to prepare in advance to apply the new rules to their own jurisdictions’ circumstances.

Your editor was also blindsided. I intentionally delay writing each Editor’s Desk column until the last moment to make it as timely as possible. This practice made it possible for me to incorporate the new mask policy into my column, but I had to throw out notes for the editorial I had planned to write, and produce copy rapidly like a journalist, rather than deliberately like an essayist.

The currently dominant virus variant, first identified in Britain and now circulating in the United States (B.1.1.7),1 is more transmissible than the original version, so the consensus threshold for herd immunity has been raised from 60%-70% to about 80%. Since almost one third of the U.S. population is reluctant to be vaccinated, many infectious disease experts, including Dr. Anthony Fauci, say it’s unlikely we will ever achieve herd immunity. Instead of being vanquished, the virus is more likely to become a manageable threat, perhaps requiring annual vaccinations.2

Columnist David Brooks called the resistance to vaccination and consequent failure to reach herd immunity “pathetic,” and wondered if this generation could have won World War II.3 Perhaps because of the misinformation rampant on the internet and social media, stoked by TV personalities whose ratings depend on fomenting outrage, people cannot trust what they are told. As a result they do not trust each other, many think only of themselves, and in the process ignore the benefit to society of having everyone vaccinated – a dangerously selfish mentality that I characterize as “your end of the boat is sinking.”

One needn’t be a medical sociologist to understand that the new guidelines will usher in a grand experiment, testing whether America today still has the social cohesion to make the new policy work.

Several considerations are salient:

a) There is virtually no possibility that we will require vaccine passports nationally. Under the new CDC guidelines – which remove mask requirements only for those fully vaccinated – mask-wearing will depend on an honor system that will force us to revise all our former presumptions about who is masked and who isn’t.4

b) Substantial numbers of people consider any mask requirement to be an infringement of their liberties, and will discard masks regardless of their vaccination status. (We used to have similar arguments about seat belts and motorcycle helmets. They’re more intrusive, but they have the force of law, and refusing them only indirectly affects others by increasing medical costs and insurance rates. It is ironic that those most concerned about individual liberties are the most likely to support a president whose conspiracy-fueled desire to overthrow the results of an election is the sine qua non of authoritarianism – the ultimate threat to liberty.)

c) Misinformation has penetrated much further into the mainstream than many realize. In an NBC/Ipsos poll conducted in December 2020,5 26% of Americans did not agree that masks are an effective tool to prevent the spread of COVID-19; 36% did not think there should be a law in their state requiring mask use in public at all times; and 41% thought that COVID-19 is no more serious than the flu.

Things aren’t much better when it comes to the most unhinged conspiracy theories. When the same poll presented the following statement fomented by QAnon to respondents: “A group of Satan-worshipping elites who run a child sex ring are trying to control our politics and media,” fewer than half (47%) said this statement was false, 37% weren’t sure, and 17% believed it to be true.

Unfortunately, when it comes to mask policies, it’s impossible to avoid political considerations. As of May 11, 2021, 25 states had statewide mask orders, including 20 of the 23 states with Democratic governors and only 5 of the 27 states with Republican governors.6

In such an intensely polarized nation, what is a vaccinated person to think when encountering an unmasked person? Are they vaccinated and following the new guidelines, or unvaccinated and opposed to mask requirements? On the other hand, is a masked person vaccinated but reluctant to adopt the new guidelines, or unvaccinated and following the rules to stay masked? Or is their motivation something else entirely – there’s no way to tell.

Understandably, many people have little faith that their maskless fellow Americans have all been vaccinated. That lack of trust, fueled by the ongoing politicization of the pandemic, undermines any public-health strategy built on the assumption that most people will do the right thing, since polls suggest that a large number will not. Those most unlikely to get vaccinated are also more likely to take risks simply because they don’t take the virus as seriously as those who do get vaccinated.7

The new guidelines make it even more important that physicians encourage their patients to get vaccinated, but that discussion cannot even begin unless physicians routinely ask their patients if they have been vaccinated. Unfortunately, this appears not to be a routine practice, though it should be.
1. https://www.webmd.com/lung/news/20210407/uk-variant-now-the-dominant-covid-19-strain-in-us#:~:text=April%207%2C%202021%20%2D,Disease%20Control%20and%20Prevention.

2. https://www.nytimes.com/2021/05/03/health/covid-herd-immunity-vaccine.html

3. https://www.nytimes.com/2021/05/06/opinion/herd-immunity-us.html

4. https://www.nytimes.com/2021/05/15/us/cdc-mask-guidance-americans.html

5. https://www.ipsos.com/en-us/news-polls/npr-misinformation-123020

6. https://ballotpedia.org/State-level_mask_requirements_in_response_to_the_coronavirus_(COVID-19)_pandemic,_2020-2021

7. https://www.washingtonpost.com/politics/2021/05/14/how-many-unvaccinated-people-will-quietly-stop-wearing-masks-now/