Anti-Maskers’ Meltdown In Covid-19 Battle

By Dr Tan Poh Tin | 13 July 2020

When private freedom collides with public health safety — individual mouth-and-nose shutdown or community lockdown?

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You might have seen videos of unmasked young women in USA throwing groceries and spewing obscenities after being asked to wear masks in shops. These fits of apoplectic meltdown followed rules in various states requiring masks in public places following the surge in Covid-19 deaths and cases.

As of July 9, USA (population 328 million) had 3.24 million cases and 136,000 have died. (Malaysia population 32.7 million, 8,696 cases, 121 deaths). A study estimates that if 80% of Americans wore a mask, the Covid-19 infection rate would drop to 8% of its current rate.

The attitudes behind the belligerent refusal of anti-maskers to wear masks are well illustrated by three Youtube cases.

In Dallas, a woman shouted as she threw her grocery items all over the floor before stomping out. “I don’t give a f**k about Dallas, your dumbass mother-f**king rules….”. In California, when stopped from entering a shop, a woman screamed “You f**king democratic pigs…I have a breathing problem. My doctor would not let me wear a mask. Anyone harassing me to wear a mask – you are violating federal law”.

In a Florida Palm Beach County commissioners’ hearing, a person (who looks like a woman) equates wearing face masks to wearing underwear: “I don’t wear them for the same reason – both need to breathe!”

Whose rights should prevail in this clash — personal freedom to choose or the rights of others to protection from the consequences of that individual’s choices?

It reminds me of the 1980s when, as the Divisional Medical Officer, Third Division, Sarawak, I set up the first government STD (Sexually Transmitted Disease) evening clinic in Sibu to provide discreet regular screening and treatment for commercial sex workers.

Prostitution was (still is) illegal but a booming business when loggers came to collect their pay and travelers stay the night on transit upriver. The transmission of STDs to their wives was an inevitable consequence, with death and malformations from congenital syphilis and neonatal gonorrhea blinding baby’s eyes.

To reduce community transmission, free condoms were issued with advice to the sex workers to protect them from getting re-infected. This did not work because invariably their clients refused to use them. The message “wear condom to protect the sex worker or your partner” did not work. So, we switched our health promotion to focus on consumers – “Use condoms to protect yourself, whoever the sex partner is, however young, however ‘clean’, HIV kills.”

The client was free to choose between knowingly exposing himself to debilitating and deadly infection and the simple and cheaper option of prevention with proper condom use or the avoidance of risky sexual contacts. This increased awareness enabled those who still got infected to come forward for earlier treatment.

However, as there is no law to require the infected person to inform the sex partner, transmission to the spouse and the unborn child continued. Hence the need for a universal and mandatory prenatal screening of pregnant women for syphilis, HIV (and Hepatitis B). This is still a cost-effective means of picking up asymptomatic transmitters (spouses/other partners), limiting community spread and protecting health care workers.

My mask protects you and your mask protects me. Our masks protect others.

The public messaging on the community usage of masks in Covid-19 has been a giddy maze of U-turns and roundabouts. No wonder some remain skeptical and uncooperative.

Despite the successful capping of SARS-CoV-2 transmission in Taiwan, Korea and Japan where the public wearing of masks is almost universal, WHO had stuck to their Interim Guidance dated April 4 against it:

“There is currently no evidence that wearing a mask (whether medical or other types) by healthy persons in the wider community setting, including universal community masking, can prevent them from infection with respiratory viruses, including Covid-19.

“Medical masks should be reserved for health care workers. The use of medical masks in the community may create a false sense of security, with neglect of other essential measures, such as hand hygiene practices and physical distancing, and may lead to touching the face under the masks and under the eyes, result in unnecessary costs, and take masks away from those in health care who need them most, especially when masks are in short supply.”

Finally, on June 5, WHO updated its guidance to encourage public mask wearing. It points to recent research that people can be highly infectious in the few days before they show symptoms (pre-symptomatic) and that some infected people never show symptoms at all (asymptomatic).

“Many countries have recommended the use of fabric masks/ face coverings for the general public. At the present time, the widespread use of masks by healthy people in the community setting is not yet supported by high quality or direct scientific evidence and there are potential benefits and harms to consider.

“However, taking into account the available studies evaluating pre- and asymptomatic transmission, a growing compendium of observational evidence on the use of masks by the general public in several countries, individual values and preferences, as well as the difficulty of physical distancing in many contexts, WHO has updated its guidance to advise that to prevent Covid-19 transmission effectively in areas of community transmission, governments should encourage the general public to wear masks in specific situations and settings as part of a comprehensive approach to suppress SARS-CoV-2 transmission.”

WHO Risk-Based Approach to Public Use of Mask

  1. Purpose: Source control to prevent spread from infected wearer and/or prevention to protect healthy wearer.
  2. Risk of exposure: where there is community transmission and limited/no capacity to implement containment measures (contact tracing, testing, isolation and care for suspected and confirmed cases). Occupation: e.g. working in close contact with the public (e.g. social workers, personal support workers, cashiers).
  3. Vulnerability of the wearer: medical masks could be used by older people, patients who are immuno-compromised or with co-morbidities (cardiovascular or cerebrovascular disease, diabetes mellitus, chronic lung disease, cancer).
  4. Setting: settings with high population density (e.g. refugee camps, dormitories or cramped conditions), and where individuals are unable to keep a physical distance of at least 1 metre (3.3 feet) (e.g. public transportation).
  5. Feasibility: availability and costs of masks, access to clean water to wash non-medical masks, and ability of mask wearers to tolerate adverse effects of wearing a mask.
  6. Type of mask: medical mask versus non-medical mask.

Individual “mouth-and-nose shut down” is more cost-effective and less socially destructive than locking down whole communities.

As of July 7, the Malaysian Director-General of Health said that 70.2% of the total 8,674 cases were asymptomatic, while 29.8% were symptomatic. The high number of asymptomatic cases was due to the targeted screening among high-risk groups in localities placed under movement control order and from the surveillance and testing on influenza-like illness and severe acute respiratory infections cases as well as pre-operative testing.

From my anecdotal observation in Kuching, everybody (except children below two years) wears masks in public places. This, in addition to the identification, quarantine and close medical monitoring of cases, and prompt isolation of contacts is perhaps why Malaysia stands out as one of the few countries which has successfully kept the locally transmitted new cases to single digits the last few weeks.

One netizen, comparing us to United Kingdom (66.6 million population, 288,000 cases, 44,650 deaths) and Italy (60.3 million population, 243,000 cases, 34,938 deaths) asked “Malaysia, Can We Borrow Your Health Minister?”.

A fusion opinion from a Sarawakian public health specialist, paediatrician, ex-associate professor, disaster relief and medical volunteer, passionate about helping people learn.

  • This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.
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