COLUMN/ THE WRITE LINE
Dr. Amitav Banerjee
Symbolism plays a major role in human perception. During the current pandemic, face masks became the symbolic shield in the battle against the novel coronavirus, while waiting for the more sophisticated artillery, the vaccine.
While scientists, slowly, unglamorously, and painstakingly reviewed the evidence, politics and propaganda hijacked the issue. Market forces, too, butted in with designer masks. Mask use or non-use became an issue for shaming, blaming, and stigmatising people. Soon to follow were mask mandates and fines.
Science was simply confined to the backstage. Mass mask use propaganda influenced people in almost every walk of life, making them substitute evidence with emotion. To date, there is no robust scientific evidence that clearly shows masks stop the transmission of respiratory viruses.
Wherever and whenever trends of Covid-19 cases and deaths went down after mask mandates, they did so due to natural phenomenon, and not due to any mandates.
The natural course of respiratory outbreaks has three phases: rise, peak, and fall. In the first phase, due to the high numbers of susceptible people in the population, cases rise rapidly till very few are left uninfected, when the peak is reached, after which there is the fall. Mask mandates are enforced most strongly during the peak. The subsequent fall in cases, which is a natural phenomenon, is often wrongly attributed to the mask mandate.
Observational studies, which are often quoted in support of mask mandates, have this limitation. Besides, without randomly allocated control and intervention groups, observational studies have other limitations, which can give spurious associations.
For example, the affluent may wear masks more often compared to the less privileged. The former will also have better housing, better access to hand-washing, and less crowded workplaces. All these will make them less likely to catch respiratory infections compared to the less privileged, and this observation will wrongly attribute the low transmission to the wearing of masks.
The best evidence comes from randomised controlled trials in which both the controls (unmasked group) and the experimental group (those who wear masks) are randomly allocated and followed forward in time. There have been two such studies during the course of the pandemic.
The first one was a Danish mask study. The results did not establish that masks were effective in reducing transmission. As the findings went against the ‘consensus’, the authors had a difficult time to find a journal that would publish their study. It was ultimately published in a journal with a caveat – the authors had to conclude that the findings were inconclusive instead of negative.
Another large-scale randomised community trial, carried out in Bangladesh, failed to establish any advantage of cloth masks in preventing transmission of the virus and showed only a very modest benefit of surgical masks. However, the study came under serious criticism with allegations of concealing important data by the investigators and underreporting any adverse effects of masks.
The last resort in resolving medical uncertainties is the Cochrane Library. It is a collection of databases containing high-quality, independent evidence aimed at helping with informed healthcare decision-making. The latest systematic review and meta-analysis, that is, the pooling the results of high-quality studies to generate the best available evidence by the Cochrane Library, concluded that the pooled results of randomised controlled trials (the gold standard in evidence-based medicine), did not show a clear reduction in respiratory viral infection with the use of medical or surgical masks. There was also no advantage with N95 or P2 respirators in routine healthcare.
The balance of evidence suggests that masks do not help. But the more important question is whether they can cause harm. The research on the potential harms of face masks is emerging. A detailed systematic review with meta-analysis raises many concerns. This paper published earlier this month brings out ample evidence of multiple harms in prolonged use of face masks, with worse outcomes for N95 masks.
The physiological and metabolic changes as a consequence of face masks can have long-term clinical consequences, especially for vulnerable groups such as children, pregnant women, the elderly, and ill people. Besides progressive lack of oxygen and build-up of CO2, there can be other changes, such as oxidative stress, constriction of blood vessels, inflammatory response, suppression of immunity, and changes at the organ, cellular, and microbiome levels and precipitation of MIES (mask-induced exhaustion syndrome).
The authors of the paper also suggest that MIES symptoms might have been misinterpreted as long-Covid symptoms.
In the Indian context, there are more serious concerns associated with the use of face masks. A study at AIIMS (All India Institute of Medical Sciences) New Delhi reported high levels of fungal contamination in face masks. During the second wave in India, which occurred in the summer of 2021, a sharp increase in Covid-associated mucormycosis, or black fungus, challenged India’s healthcare system.
By the end of June 2021, India reported over 40,000 cases of mucormycosis. While mucormycosis was attributed to misuse of steroids and pre-existing diabetes, we cannot rule out the role of soiled face masks contributing to the growth of fungus and other pathogens.
Indian summers are hot and humid, and a face mask can get soiled within a couple of hours. This can provide ideal conditions for growth of fungus. The concern regarding the role of face masks in mucormycosis has also been raised by a paper in the Journal of Global Infectious Diseases.
Against the above background, of weakening evidence of benefits of face masks and increasing concerns of serious adverse effects including black fungus that maimed and killed many during the second wave of Covid-19, we can conclude that the recommendation of masks should be reconsidered. More so, when there is evidence that the Omicron variant of the virus and its sub-lineages are able to spread more swiftly, overcoming all physical and distancing barriers.
Mask use by the general public, particularly in the summer months, is hazardous and should be discouraged. The issue should be addressed in a strictly scientific manner without any political influence, and from a humanitarian and ethical point of view. The balance of evidence points to more potential harms than benefits.
Science, which has been suppressed for so long during the pandemic, should be revived, failing which, more people may die.
(Dr. Amitav Banerjee was a field epidemiologist for over two decades in the Indian Army. He led the mobile epidemic investigation team at the Armed Forces Medical College in Pune, India, from 2000-2004. During this period, he investigated a number of outbreaks in the country. He is presently a professor in a medical college in Pune.)
The column reflects the author’s opinions and not necessarily those of Empire Diaries.
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