The masks and the experts

America's Covid problems are bigger than Trump

Hello. I’m kind of obsessed with the ways that Trump’s boorish behavior around the pandemic has halted scrutiny of other failures on the American response and I want to continue with that theme today.

Last week I wrote about how the expert consensus on travel restrictions turned around during the course of the pandemic. In that case, I think you can at least legitimately say that if public health experts had called for a draconian shutdown of international travel they’d have been overruled.

By contrast on masks, what happened is that initially we were seeing mask-adoption driven by grassroots decision-making and experts stepped in to intervene and tell people not to wear them. That probably counts as the biggest failure of the expert public health community, and I think it bled into a larger lag among experts to really emphasize the central role of air flow in the spread of the virus.

The early mask guidance made no sense

I will put my cards on the table here. I bought a box of procedure masks sometime in mid-to-late February when the official guidance from the government and in the media was anti-mask. Not because I had any particular insight into the matter, but because the things we were being told about masks were just illogical.

Elizabeth Rosenthal writing in the New York Times opinion section did a January 28 article telling people to wash hands instead of focusing on masks:

Americans are watching with alarm as a new coronavirus spreads in China and cases pop up in the United States. They are barraged with information about what kinds of masks are best to prevent viral spread. Students are handing out masks in Seattle. Masks have run out in Brazos County, Tex.

Hang on.

But then in the fifth graf of the story she explains a bunch of situations in which it would be good to wear a mask:

Having a mask with you as a precaution makes sense if you are in the midst of an outbreak, as I was when out reporting in the field during those months. But wearing it constantly is another matter. I donned a mask when visiting hospitals where SARS patients had been housed. I wore it in the markets where wild animals that were the suspected source of the outbreak were being butchered, blood droplets flying. I wore it in crowded enclosed spaces that I couldn’t avoid, like airplanes and trains, as I traveled to cities involved in the outbreak, like Guangzhou and Hong Kong. You never know if the guy coughing and sneezing two rows ahead of you is ill or just has an allergy.

Isaac Bogoch from the University of Toronto dismissed mask-wearing as “overly alarmist” on January 29, but in the same interview conceded “if someone has a respiratory infection, masks are helpful at stopping spread.” There was a CDC study circulating at around this time which concluded that masks are “ineffective for controlling seasonal respiratory disease” but if you read what it says in detail that’s because “household use of face masks is associated with low adherence.”

My thinking, as of mid-February, was that according to the experts who said we didn’t need masks we actually did need masks:

  • If infection became widespread but it wasn’t possible to just stay home, you’d want to wear a mask when you were around other people [Rosenthal]

  • If you got sick, you’d want to wear a mask — and you presumably wouldn’t want to go to the store coughing all over everyone to buy it [Bogoch]

I was not actually wearing a mask at this time, I just had the box in case we needed them which seemed prudent according to the anti-mask messengers. Then there started to be more buzz that the real issue here was simply that the government was afraid of shortages. On February 29, the Surgeon General just blurted out that masks are simultaneously ineffective but also actually very necessary for health care providers:

Dr Fauci later told Norah O’Donnell that Surgeon General Adams’ concern about shortages was driving the train the whole time: “We were told in our task force meetings that we have a serious problem with the lack of PPEs and masks for the health providers who are putting themselves in harm's way every day to take care of sick people.”

I at this early March point went through one of the least-proud moments of my career and decided I didn’t want to take the heat for deviating from the expert consensus when I was a non-specialist. I had a few friends in Asia who explained to me that it was very possible to get around the shortage problem by using cloth masks, which I took under personal advisement and started maybe RTing some Lyman Stone tweets about, but I didn’t try to pitch any stories. It fell to Zeynep Tufekci to really break ground with an influential New York Times op-ed arguing that the effort to manipulate and deceive the public was counterproductive. After her piece the floodgates started to open (German Lopez did a great review for Vox, which had previously been solidly anti-mask, of the evidence for masks) and by early April the CDC was asking people to wear cloth masks to prevent the spread of virus without causing shortages of medical equipment.

But even when the message pivoted, it never really pivoted.

We never got a clear message on ventilation

Washing your hands is, obviously, a great thing to do in life. But the forget-masks-wash-your-hands era, even if motivated by a concern about medical supplies, carried a larger implication that’s stuck with us — fear dirty things. The correct message should be to fear contaminated air.

When I went to Austin to record with Joe Rogan, I stayed in a hotel which, naturally, was eager to make customers feel like it was a safe place to stay. They emphasized their “enhanced cleaning procedures” especially on “high-touch surfaces” and the remote control for the TV even came closed in some kind of plastic bag. In compliance with current thinking, they of course did have signs up everywhere about the importance of wearing masks. But also the hotel’s lobby bar was open, so there were people sitting around maskless drinking and talking right in the lobby.

California for some reason kept playgrounds closed until late September. Derek Thompson wrote about “hygiene theater” at restaurants, which was both wasting time and money at outdoor tables that were perfectly safe and giving people a totally unreasonable sense of security about indoor dining.

You can buy the Wirecutter’s recommended best HEPA air purifier on Amazon right now with two-day Prime shipping. In some ways that’s great, America is not out of stock of air purifiers. But the fact that we aren’t out of stock of air purifiers itself reflects a huge failure to provide adequate information. It should be the case that every business looking to reassure customers is prominently setting up air purifiers as an additional line of protection to supplement masks. There should have been no indoor eating or drinking anywhere in America during times when the weather was decent. And there never should have been restrictions on outdoor activity.

Meanwhile, having belatedly come around to the view that cloth masks were the solution to the shortage of procedure masks the powers that be have never wanted to pivot back to the point that it’s better to wear high-quality masks. But once hospitals weren’t running short on medical supplies, the government should have tried to persuade people to wear the best possible mask. And they should have used the Defense Production Act to ensure that good masks were widely available.

We need a pandemic after-action report

Fundamentally, I don’t have anything original to add to the basic dialogue around masks and ventilation. Tufekci wrote the most important early article about masks and she also wrote the best article about the central role ventilation should be playing in our mitigation strategy. I don’t see anyone in the media who agrees with California’s aversion to playgrounds and I honestly have no idea what’s been driving the governor’s thinking on that.

But what I do think we need is for some time in 2021 for the government to order a serious review of what the public health agencies were saying and doing about this stuff and why. Not to point fingers, but in the spirit of the kind of after-action reports the military routinely does. Because clearly something went wrong and there’s a need to assess how decisions were made and how we can do better next time.

I’m afraid it won’t happen though.

Sources I’ve spoken to in the political world tell me that Biden’s vague campaign messages to “listen to the experts” and “follow the science” tested very well. There’s always a lot of emphasis in the press on loud anti-maskers and covid denialists, but the evidence is that most people want to follow the experts’ lead and strongly disapprove of the way Trump derided them. So the political safe zone is to just ride the “experts are good” message, hand out vaccines, and leave the Republicans to deal with the fact that they now have a bunch of maniacs in their base.

But while a 60/40 issue is really good in electoral politics, in actual public health it’s not good enough. We need to get to a point where a larger share of the public has confidence in the experts and the public health authorities. And the fact that the authorities seem to have been deliberately misleading people about masks — and doing so because they lacked the creativity to think of the cloth masks as an alternate solution — is not great for building anyone’s confidence.

America’s Covid problems are bigger than Trump

More broadly, I’m really concerned that lashing out at Trump (who, to be clear, is terrible) is serving to sweep under the rug the extent and scope of the failure of the western public health community.

The United States is doing considerably worse than Canada during this pandemic and I think that when all is said and done we’re going to end up in a worse place than Europe. But the US/Canada gap is small compared to the Canada/Vietnam gap, and the US/Europe gap is smaller than the US/Canada gap. Internal to the United States, there’s a big difference in the political rhetoric around the pandemic but the actual policy choices have not been all that different and the outcomes also haven’t been different.

Nobody in American politics really pushed for centralized quarantine or for travel restrictions. Early in the pandemic Paul Romer touted massive surveillance testing as a possible solution that was more in keeping with the temper of American political culture, but even though this got a lot of cheerleading from people (like me!) who follow economics twitter closely it was never anywhere in the public debate.

I know the public health community has a lot of raw feelings right now after being so blithely dismissed by Trump and tossed into the maw of partisan politics. And I agree that we could have parked this in a better outcome had Trump listened to them more closely.

But to get to the kind of dramatically better outcomes that we see on the other side of the Pacific would have required an approach that was more different from the range of outcomes under consideration in the United States. Maybe there are good reasons for that and enforceable quarantines, mandatory testing, and travel restrictions never would have flown in the United States. But the confused dialogue around masks and ventilation and the superior performance of countries exposed to SARS suggests to me perhaps simply that people and institutions were not adequately thoughtful about the specific dynamics of a respiratory illness which, after all, is quite different from Ebola or HIV/AIDS.

Whatever the real reason, we as a country need deeper thinking and deeper answers than just “Trump screwed up.”