The Rhyming History of Masks

Masks were seen as a salvation during the 1918 influenza pandemic. What happened next was remembered for one hundred years. We forgot it in 2020, but our memory is slowly returning.

I’m not particularly eager to continue arguing about the efficacy of masks to reduce the spread of Covid. It’s funny to me that Derek Thompson feels the same way and wrote a piece that is incredibly worthwhile in The Atlantic entitled Why Are We Still Arguing About Masks? Simply asking that question makes me think that we are on the same page.

In some ways, we are. Thompson confronts the utility of masks by addressing the Cochrane metastudy, which looked at 78 randomly controlled trials (RTCs) on masks and concluded “We are uncertain whether wearing masks or N95/P2 respirators helps to slow the spread of respiratory viruses.”

He also talked with the authors of some of several “masks are effective” studies (including the famous Bangladesh study), who dismissed the conclusions of the Cochrane study in no unclear language, calling it “scientific garbage.”

Thompson did ultimately conclude by encouraging his readers to be substantially less certain on the topic which I think (I hope?) encourages people to show more grace. At this stage, that’s a valuable principle to advance.

As we stumble our way through history I’m fascinated to discover that we seem to be on a path that has been trodden before. I suspect we are in the later stages of the exact assessment on the efficacy of masks that we had a hundred years ago during the influenza pandemic of 1918, commonly known as the Spanish Flu.

As I read through John Barry’s The Great Influenza this last year and hunted down his source material on masking, I was struck that the history of masking and public health in the 1918 pandemic followed this pattern:

1. Physicians and scientists determine that masks are valuable in a clinical setting.

2. Public health officials make masks mandatory or otherwise create enough fear and social pressure to get a large majority of the population to use masks.

3. Masks prove substantially less effective outside a clinical setting, causing people to distrust government recommendations.

4. The pandemic wave hits the population anyway, often after people stop wearing masks.

5. Studies are done after the pandemic determining that, at best, masks delayed a pandemic wave.

6. Public health experts stop recommending masks because trust is too valuable a commodity to spend on an NPI that has no long-term impact.

We got to the final position many decades ago and it has been considered common knowledge among public health experts since then. We forgot it during the COVID pandemic and we are currently at about stage 5. The biggest difference is that we still have many public health officials and scientists insisting that stage 3 is untrue and stage 4 is the fault of the dumb people, not the masks.

But the history of this pattern is important to review.