By Felicia Ho
Last week, the CDC revised its policy regarding the general public’s use of face masks. It now recommends wearing cloth face coverings in public settings (especially in known areas at-risk of significant high community transmission). This is a recent revision and U.S. health officials were not actively advising the public to use face coverings previously. In late February, U.S. Surgeon General Jerome Adams 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!”
Why the new guidelines advocating for cloth face coverings?
The CDC cites several studies showing that those lacking symptoms (asymptomatic) and those who would eventually develop symptoms (presymptomatic) can also spread the virus. As COVID-19 is known to be transmitted through droplets produced from speaking, coughing, or sneezing in close proximity with others, the cloth face coverings the CDC recommends would act as a barrier to these droplets. Although home-made cloth face coverings have been proven to be not as effective as surgical masks in reducing exposure to aerosol droplets, some protection is better than no protection. More importantly, medical workers - many of whom are facing personal protective equipment (PPE) shortages in the U.S. - with daily exposure to COVID-19 must be considered the priority in having access to surgical masks and respirators (N95s or the recently approved KN95s). As the CDC recommends, please reserve all surgical masks and respirators for health care workers and use cloth face coverings yourself, and if you have these resources, it would be amazing to donate them to your local hospital as well.
How does the new US cloth face covering policy compare to other countries?
Unlike the United States, China, South Korea, Japan, and other Asian countries have encouraged the use of face masks since the beginning of their respective experiences with the virus. This stark comparison may be due to a variety of factors, spanning from differences in cultural norms to their histories of managing similar respiratory diseases like SARS, and may have other consequences in affecting the speed and scope of virus transmission.
After the SARS epidemic in 2003 killed almost 300 people in Hong Kong, wearing face masks to protect both yourself and others from the virus became almost a given. In the midst of the current COVID-19 epidemic, it seems that Asian cities like Hong Kong have remained relatively stable in its number of cases and deaths in comparison to similarly densely populated cities like New York. As of April 8, there are 961 cases and four deaths in Hong Kong, and much of the city remains open. Could their widespread and largely voluntary use of face masks be one of the answers to their success in managing this pandemic?
The social pressure to wear face masks is clearly evident in these cities, with The Wall Street Journal reporting that “No mask, no entry” signs are frequently found outside Hong Kong supermarkets and on taxis. Carrie Lam, Hong Kong’s Chief Executive, was even recently criticized for not wearing a face mask during a press conference - a practice to which President Trump and his COVID-19 task force team still do not adhere.
Beyond social pressure, governments, too, are asking residents to use face masks in public and are encouraging the purchase of surgical grade or respiratory masks. While the majority of the U.S. is only recommending the use of cloth face coverings at the moment, the CDC’s recent shift in mask guidelines have influenced some cities, including Los Angeles, to implement stricter face-covering rules. The South Korean government rolled out a program to control the production and consumption of face masks: 23,000 pharmacies would sell KF-94 (similar to N-95) masks at around $1.20 per mask, with a rationing system designed to only allow a certain number of people to queue in line at local pharmacies at a time. Although fascinating in concept, this policy has also been met with several obstacles, including maintaining sufficient supply of masks at pharmacies to meet the demand and the quota on the number of masks each person can buy.
Whether Hong Kong and other Asian countries’ prevalent use of face masks proves to be a significant factor in their effective control of COVID-19 transmission and spread remains to be seen. As some of these cities work to control the recent spike of imported cases, it is important to note that many other factors - widespread and fast testing, strict contact tracing, and more - may also play large roles in their swift and effective responses. We must learn from these practices as well and take note on how they can be re-implemented and modified for the U.S.
Why does this almost natural embracing of face masks in Asia exist while many Americans (including the President) continue to feel uncomfortable wearing a face mask covering?
This question is heavily debated, but it may be of use to draw upon the different social norms between these two cultures. One reason may be the greater emphasis on the well-being of the community, as opposed to the individual, in Asian culture: face masks are not only used to protect yourself, but they are also used to protect others from being exposed to your germs and viruses. In other words, wearing masks is a form of respectful social etiquette. In aging populations like Japan’s, this is particularly important in protecting the elderly from even a minor cold. Some also suggest that there may be a difference in how we perceive others as well, particularly when we are first meeting one another: while the firm handshake, upfront eye contact, and smile are crucial to landing a job or more generally equate to success in America and other Western countries, there may be less of an emphasis on visible facial expression in Asian cultures. As a result of these factors and many more, face masks are a common sight in Asian countries, whether it be during flu season, allergy season, or even in fashion shows as a form of self-expression.
Unfortunately, the difference in accepted cultural norms for face masks, compounded with a host of other issues including the President’s insistent push to call COVID-19 “Chinese virus,” has fueled a wave of Asian discrimination worldwide that ignited in the early stages of the COVID-19 crisis and continues today, even as the virus has swept past Chinese borders. The New York Times recently published several first-hand experiences of discrimination that Chinese-Americans have faced. When taken with other daily accounts like the video of a woman wearing a mask being harassed in a New York subway station, there are simply no words left to describe the injury and pain. The face mask, a regular practice and rule of social etiquette for many Asians simply trying to maintain their own health and that of others, has become a target.
Moving Forward
While the new CDC recommendation for wearing cloth face coverings seems to be a step in the right direction, many questions remain: will this incite a renewed fear in the American public and consequently instigate hoarding of surgical and N95 masks? More importantly, we must ask ourselves: why are physicians in overwhelmed hospitals in the U.S. facing a shortage in their medical mask supply? Is it because of hoarding by the public or is it the result of a greater, systematic issue of a lack of public health preparation by the government - a fundamental lack of sufficient funding and resources to manage this pandemic?