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Friday, July 10, 2020

LONG READ: Face masks are the new condoms: How a public health preventive measure will sav

Only six months ago, a young man walking into a bank, demanding to withdraw money at the counter would have been viewed with instant suspicion. People
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Only six months ago, a young man walking into a bank, demanding to withdraw money at the counter would have been viewed with instant suspicion. People would’ve stared uncomfortably and bank security most likely would have been forced to approach him.

Today, it is the other way round. This situation isn’t limited to banks. A lot of establishments from airports to corner shops now have notices clearly displayed to the general public. You will only be let in if you are wearing a face mask. These establishments aren’t just acting on a whim, they are taking public health advice.

Welcome to the new normal.

In June, the World Health Organization (WHO) sort of refuted earlier directives it had made about prevention methods for the Coronavirus pandemic by broadening recommendations for the use of masks for citizens who hadn’t contracted the deadly virus. After earlier insisting on limiting increasingly scarce face masks for health care workers, people with COVID-19 and their caregivers, the WHO now advises that in areas where the virus is spreading, people should wear fabric masks in situations such as public transportation, markets and malls where social distancing is not entirely possible. With countries reporting more than 150,000 new COVID-19 cases to the WHO on 18, June, the most in a single day so far, it is fair to assume that the virus is spreading everywhere. And so this advice implicates everyone.

In its own guidelines for using face masks, the Nigeria Centre for Disease Control (NCDC) advises that cloth face masks, made out of everyday fabric can act as a barrier to respiratory droplets but cannot on their own prevent spread of the coronavirus. They should be used in addition to other preventive measures. You know which ones. Avoiding large gatherings, maintaining physical distancing of at least 2 metres, regular handwashing with soap under running water and frequent cleaning of surfaces with soap and water.

All of these make sense considering the nature of transmission of the coronavirus. There are still many unknowns but data from published epidemiology and virologic studies provide evidence that COVID-19 is primarily transmitted from symptomatic people to others who are in close contact through respiratory droplets, by direct contact with infected persons, or by contact with contaminated objects and surfaces. Because there is no drug treatment or vaccine available to prevent new infections, the virus continues to spread exponentially.

Globally, lockdowns and movement restrictions have helped to blunt the edge of the deadliest effects but as countries loosen restrictions to resume economic activity, it is clear that face masks will become the public face of the battle against the virus. In a recent article, The New York Times surveyed 511 epidemiologists and more than half of them predicted that face masks will be necessary for at least the next year, if not longer.

The reason is simple, and of course depressing. According to all the knowledge of science that is available, a vaccine is the most effective way for a population to achieve “herd immunity” from any disease. This means that the disease will only come to a natural end once 60-70% of people become immune to it. The alternative will be to let the virus run its natural course until this goal of 60-70% is achieved. With proper physical distancing measures in place, some epidemiologists argue that this could take two years, during which time a vaccine could hopefully be developed.

A brief history of the face mask

Records are scarce but it appears the earliest record of face mask-like objects in human history date back to the 6th century BC. In that period, it is reported that images of people wearing cloth over their mouths were found on the doors of Persian tombs. In China, a kind of scarf woven with silk and gold threads from the Yuan Dynasty (1279-1368) is believed to be the earliest item in China that is similar to today’s face mask. This was worn by servants who served the emperor during meals to prevent the servants’ breath from affecting the smell and taste of the food.

According to the Lancet article, A History of the Medical Mask and the Rise of Throwaway culture, written by Bruno J Strasser and Thomas Schlich, face masks as used in modern living- in health care and in the community- can be traced back historically to the 19th century, a period that coincided with a more widely accepted understanding of contagion based on germ theory. This knowledge was subsequently applied to surgery.

In the 1880s, a new generation of surgeons devised the strategy of asepsis, a preventive protocol aiming to stop germs from entering wounds by minimizing potential sources of risks such as instruments, exhalation, surgeon’s hands as much as possible.

Johann Mikulicz, head of the surgery department of the University of Breslau (now Wroclaw, Poland) while working with the local bacteriologist Carl Flügge started wearing a face mask for proceedures in 1897. He described the mask at the time as “a piece of gauze tied by two strings to the cap, and sweeping across the face so as to cover the nose and mouth and beard.” This was in response to Flügge’s experimental work which had shown that respiratory droplets carried culturable bacteria. In Paris, the surgeon Paul Berger also began wearing a mask in the operating room the same year. The face mask at the time was a strategy of infection control that focused on keeping all germs away, as opposed to killing them with chemicals.

However, masks became increasingly widespread. A study of more than 1000 photographs of surgeons in operating rooms in US and European hospitals between 1863 and 1969 indicated that by 1923 over two-thirds of them wore masks and by 1935 most of them were using masks.

By the time the influenza pandemic of 1918 rolled around, people were more receptive to wearing face masks at the community level. In places like Japan, the government advocated face masks as a way for the healthy to protect themselves rather than for the sick to avoid infecting others. Citizens took to this trend enthusiastically and it soon became part of the culture. As a result, they were better primed to agree with WHO guidelines in response to the Sars epidemic that followed decades later in 2003 as well as the avian flu of 2004. Even though these guidelines emphasized face masks for people with symptoms, healthy people chose to wear them as well. A combination of the seasonal flu, H1N1 in 2009 and the Fukushima nuclear disaster in Japan in 2011 further helped institute a culture of mask wearing in the region.  Eventually, in many Asian countries, the surgical mask simply became common winter wear.

How face masks work

The effectiveness of face masks is based on the scientific assumption that people who have severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), the causative agent of COVID-19 can continue to transmit the virus even while asymptomatic.

Before the coronavirus became a thing, surgical masks were the most identifiable type. Common in hospitals and clinics as a loose-fitting disposable plug that protects the wearer’s nose and mouth from contact with droplets, splashes and sprays that may contain germs. The surgical mask also filters out large particles in the air and may protect others by reducing exposure to saliva and respiratory secretions of the mask wearer.

With the coronavirus. came the popularity of the N95, preferred face gear of Nigerian politicians and big men. A type of respirator, the disposable N95 mask offers better protection than a surgical mask does because it can filter out both large and small particles when the wearer inhales, blocking 95% of very small particles. Some N95 masks even come fitted with valves that make them easier to breathe through. But because the valve releases unfiltered air when the wearer breathes out, these types of mask doesn’t prevent the wearer from spreading the virus.

No one told Nigerian big men and women that ideally, health care providers whom the N95s were made for originally should be trained to use the masks. They are to pass a fit test to confirm a proper seal before using the N95 respirator in the workplace. Well enough, as many of the masks currently in circulation are not of the best quality. Some N95 masks, and even some cloth masks, have one-way valves that make them easier to breathe through.

Because they are easy to make, effective, readily available and can be washed and reused, cloth masks are a fine alternative to tools urgently needed by health care workers. Places like China- as much as their data can be reliable- and other Asian countries that made face masks an early requirement alongside wide testing, isolation and social distancing seem to have had better success with slowing the spread of the virus.

Face masks as the new condoms

In Nigeria and parts of the developing world where another pandemic, HIV/AIDS is still an ongoing concern, the several conversations surrounding face masks bring to mind another barrier preventive tool of immense public health significance, the condom.

Condoms have a long and fascinating history dating back to ancient civilizations.

According to the scientific paper, The Story of the Condom (published by Fahd KhanSaheel MukhtarIan K. Dickinson, and Seshadri Sriprasad) in the Indian Journal of Urology. The first use of a condom is credited to King Minos of Crete and his wife Pasiphae. She employed a goat’s bladder in her vagina so that King Minos would not be able to harm her as his semen was said to contain “scorpions and serpents” that killed his mistresses post coitus. He probably was a super spreader of a sexually transmitted disease.

During the renaissance period, Gabriele Falloppio, the prominent Italian anatomist credited with describing the Fallopian tube in the book,b De Morbo Gallico following his experiments on 1100 men, describes a sheath of linen used for protection against syphilis. The sheath which covered the glans penis was fastened with a ribbon and lubricated with saliva. It protected all the men from contracting the disease.

This disease-preventing use of condoms was somehow sidelined and condoms become identified mostly for the contraceptive properties, it wasn’t until the HIV pandemic started ravaging swathes of the United States of America that condoms as disease preventing tools entered the mainstream and became popular again.

Just like condoms, despite the documented benefits, there has been resistance to the use of face masks to respond to COVID-19. Nigerians seemed to have bought into the use at the peak of the national response when fear was widespread and every country was pretty much bracing for a surge in morbidity and mortality. But on a behavioral level, face masks simply aren’t sticking.

People know to leave their houses with their face masks but wearing them is quite another matter. Many who do, keep them as an afterthought, under the chin, behind the ear, in their purses, anywhere but on the face to properly cover the nose and mouth. Despite the continent’s contemporary history with infectious diseases (Malaria, HIV, Ebola), Africa has largely been spared the burden of respiratory droplets transmitted or airborne diseases like COVID-19. Perhaps because of this, the culture of wearing face masks is proving harder to settle. COVID-19 should change this anyway.

Behavioral vs cultural

Not helping are attitudes in the global West, regions that are more likely to influence culture, health seeking and general behavior in Nigeria and other sun Saharan countries. In the United States for example, face masks have become a political and cultural flashpoint with a clear and present divide drawn between those who wear them and those who choose not to.

President Donald Trump prefers to be seen maskless even in public spaces where risk of transmission is higher. His Democratic party opponent in the forthcoming elections, Joe Biden makes it a point of duty to be seen publicly with his. Vice President once attended a Mayo Clinic without wearing one. A recent Quinnipiac University poll shows overwhelming support  (90%) among Democrats for mask wearing, but not so much for Republicans (38%). Many states have placed the burden on enforcing (or not) enforcing mask rules on business owners, with politicians choosing to stay out of the fray if they can help it.

In Nigeria, perhaps it isn’t quite a culture issue as it is a behavioral one. The Presidential Task Force on COVID-19 has made face masks compulsory at its briefings. The Lagos state governor Babajide Sanwo-Olu is an advocate for face masks, as are many of his colleagues and they have largely led by example. But president Muhammadu Buhari, unbothered as ever, has repeatedly appeared publicly unmasked. Even after losing a close aide to the rampaging viral disease.

The HIV playbook

So what will it take to make face masks a thing?

Solving the face mask impasse may involve going right back to condoms and the last pandemic that the world can remember for lessons. The coronavirus and HIV are similar in three important ways. People can be infected and transmit both viruses without knowing so. Both viruses can spread through bodily fluids. And neither condoms nor face masks, both protective measures, are 100% protective even though they make risky behaviors safer.

On their own, face masks and condoms are not quite perfect but in the long run they are far better than nothing.

It may be wiser to deploy a global public health campaign as was done for condoms in the 90s to ensure that face masks are widely accepted and readily available. Just like asking people to abstain from sex proved to be unrealistic, expecting people particularly in densely populated places to stay 1 or 2m from each other is unlikely to be effective. This is where face masks inevitably come in.

For face masks to become a mainstay in Nigeria and similar places, there has to be a market to ensure a large, steady supply, made on the cheap, locally driven and of good quality. Masks simply won’t work if people don’t use them consistently and correctly and this means expecting your neighbor to protect you the same way you are protecting them. The public health communication campaigns to drive uptake of face masks must include local input, consumer insight as well as motivation to use, care for and dispose masks properly.

As the COVID-19 pandemic has clearly demonstrated, when it comes to public health interventions; from testing and isolating cases to quarantine and lockdowns, nothing is quite new. Even when diseases are novel, there is likely already a prototype in place for building effective prevention and control measures. Best be prepared for a world with masks in the next couple of years.

At least you can still shoot dirty looks.

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