It's past time to throw away routine, forced masking in health care facilities

Wearing a mask from the door to the dentist chair is a waste of time, while N95s in COVID+ rooms are still reasonable.

Sep 13, 2022

Most health-care facilities in the United States have not yet embraced what hundreds of millions of Americans have: throw away the mask, and return to normal. For hospitals this means “Yes, you can choose to wear an n95 mask in a Covid + patients room,” but “No, we don't need to force mask all visitors and all workers in the hallways between sips of coffee”. For the dentist’s office, this means that after you keep your mouth open for an hour, you don't need to put a mask on to walk back to the door. These are policies that no longer make sense in Sept 2022 and have to go.

I usually start with efficacy, but this time let’s begin with harms and downsides. Masking is a burden. If it were not obligatory, few would do it. Want evidence? Exhibit A: everywhere in America. Masking use on airplanes is almost gone. Masking in grocery stories is just a dream. Masking in restaurants and bars— non-existent. Well, except for servers and kids in headstart, who are powerless.

Masking has real downsides, particularly in hospital and clinic settings. Masking muffles speech, and irritates skin, noses, cheeks, etc. Masking makes it harder to read emotions and gauge reactions— both for your colleagues, your staff and your patients.

Masking harms patient care for older people who are hard of hearing. It harms people who are acutely short of breath. It harms older people seeking care for suspected stroke (did they suddenly develop facial droop?). It harms women giving birth (forced to mask during contractions— why? they just tested negative anyway). It prevents people from seeing your facial expression. In many cases, harm may be limited to subjective discomfort— but guess what: that is still a harm. Unless masking in hospitals has a clear upside, it has to go.

In terms of efficacy, there are zero high quality studies that universal hospital visitor masking on any important outcome. But more importantly, even if there were, that might apply to 2020, but as of Sept 2022, it no longer makes sense.

Have you walked around America? Flown anywhere? No one is wearing a mask. Most Americans have been vaccinated, had Covid, or both. In the short term, 93-97% of all people on earth will get COVID. In some age groups, we are likely already at that saturation point.

Passing out sea-turtle strangling surgical masks to hospital visitors will have zero impact on the time till total Covid19 saturation— even if worn perfectly, given the absolute lack of use outside the hospital. But consider also that they are not worn well at all.

Recently, I visited a few hospitals in different cities. I saw masks off for tea, coffee, food. I saw more noses than I could count. More masks spill out of boxes on the floor than tightly seal lips and noses.

No one wants to enforce the policy. I saw joggers duck into one hospital (it was urban and had restaurants and shops on the ground floor), maskless, and duck out, and no one said a word. Who would?

What should we do? Of course, anyone who wishes can do whatever they want. Patients who want protection can wear tight fitting n95s. Perhaps hospitals can offer fit testing for truly vulnerable, transient immunosuppression. Why haven’t they already?

Doctors who have not recently had BA4/5 can choose also to wear n95 in known COVID positive rooms. Of course, if I have not been recently infected, I would take that choice any day of the week. The short term application of a tight fitting, fit tested mask for a double digit absolute risk reduction over 15 mins is worth the short time. A doctor just getting over BA4/5 (non-infectious now) might make a different choice. Forcing a doctor who just had covid to wear a tight fitting mask to protect other patients doesn’t make sense for the simple reason that the doctor could acquire covid in that room, yes, but also in a million other places outside work, and you cannot patrol all those places. And also because having just had covid, they are unlikely to get it again.

Of course, healthcare workers who are actively sick and infectious should not be working, but guess what? They never should have, and forcing a sick health care worker to wear a flimsy surgical mask (99% of hospital policy) is little protection for a patient. A false protection.

Ultimately there is no longer any good reason to force people in hospitals to wear masks. People can make their own choices. Everyone will get COVID in the short term, and people are adult enough to decide what risks they want to take. This has always been how the world works, and always will be. Finally, here is a tweet I saw that I have no comment on, but perhaps you do.