Masks are not benign

Comparing wearing a mask with wearing a seatbelt is not accurate

Seat belts do save lives. I always wear one. I mostly forget that it’s on, except perhaps if I’m trying to reach way back in the car to get something. I personally don’t agree with seat belt laws, but perhaps that’s just my libertarian streak coming out. (Like Matt Strauss, I don’t agree with mandatory bike helmets either). But there is no question that seat belts work. I choose to wear mine. And they were only made mandatory after several decades of accumulated data proving that they worked to save lives.

Masks are an example of the weaponization of the precautionary principle. “If it saves just one life, it is worth it”. “You can’t be too careful”. Neither of these is true. A correct application of the precautionary principle means considering not only the benefits, but also the negative impacts of an intervention. Some people are killed by beestings. So should we eliminate all bees? It would save more than one life, so wouldn’t it be worth it? You could stay safe from COVID by not leaving your bedroom for a year, but would that be “too careful”? Might the isolation and eventual starvation outweigh the COVID risk reduction?

Thomas Sowell said “There are no solutions. There are only trade-offs.” When we rushed into masking the world, we should have first considered the downsides. Better late than never, here is my attempt to elucidate some negative impacts of masks that our overlords (medical officers of health and politicians) did not, but should have, considered and discussed.

Gas exchange - it’s not about the oxygen

Instinctively none of us thinks that breathing our own exhaust fumes is a good idea. There is nothing better than that first breath of fresh air after you’ve been somewhere stuffy and enclosed.

But blood oxygen levels are relatively unimpacted by masks.

In the ER we use a drug called propofol to put people briefly to sleep to do things like pop their dislocated shoulder in, or set a broken bone. We jokingly call it “milk of amnesia” because it is white and opaque in the syringe. One side effect is that it slows or even completely stops the patient’s breathing. But the sedated person has a store of O2 attached to hemoglobin in his blood, and can still absorb it from the air stored in his lungs. Air is 21% O2 - more than we need (at least at sea level). So it actually takes several minutes after breathing stops for one’s oxygen level to fall. We ER docs love propofol because it wears off so quickly that if we get the dose right, the patient is starting to breath again before his oxygen level has a chance to fall. No harm, no foul.

So despite the fears of many, oxygen levels are not what we should worry about. A doc proved this by going for a run with an oximeter (blood oxygen measuring device) on his finger, and a mask on his face. He showed that there was no fall in his oxygen level and declared that masks had no adverse effects, and that we “anti-maskers” were being ridiculous. What he actually proved is that he is an idiot. Anyone with even a basic understanding of respiratory physiology could have told him that his oxygen level would indeed stay just fine (although I’d love to see him do a race, rather than a jog, and repeat the result - vigorous exercise is a different beast). Oxygen is not the problem in most cases.

CO2 – carbon dioxide - is actually the gas that we should be discussing.

If you hold your breath for more than 30 seconds, you start to get an urge to breathe. After a minute or two it becomes irresistible. Your oxygen isn’t falling significantly yet, but your CO2 is rising. Our bodies are finely tuned to sense CO2 buildup. Ever experience a crowded and stuffy room full of people? Everyone starts yawning and gets sleepy? It might be a boring lecture (is Chris Milburn speaking again today?), but it may be that CO2 levels have crept up a bit. And opening the window or turning up the HVAC can alleviate the problem. Even at slightly elevated levels CO2 seems to have effects on our mental alertness and focus, even if it doesn’t present a “danger” per se. And masks do seem to cause slight elevations in CO2 according to several studies.

Heat Dissipation

With our weather in Cape Breton, this is not always relevant. But in many indoor situations or in hot weather outdoors it can be. We are as inefficient as a car engine. We produce 3 units of heat for each unit of useable energy: heat which our always-metabolizing bodies need to dissipate somehow. One of the main ways is through respiration. That’s why your breath feels warm on your hand. This is more of an issue for kids and the elderly, who have a greater risk of hyperthermia. I have had several elderly patients who fainted at least in part as a result of feeling too warm and stuffy in their mask. I’ve also had many younger folks who have fainted, or nearly so. The natural reaction for someone who feels faint and weak is to rip off his mask and try to get some fresh air. Our body knows best.

Foegen Effect

Could masks actually make you more likely to catch COVID, or make it worse if you do? The proposed “Foegen effect” has some evidence in animal models but is “not ready for prime time”. But several population level studies hint that maybe it is a real phenomenon, as more masked areas have had worse COVID numbers than less-masked. The Foegen effect concept is that droplets full of virions (viral particles) are hypercondensed on the mask. They dry out and are concentrated - thus transformed so that they can then be more easily breathed deeper into the lungs.

Toxic Substances in Masks

I had a family in my practice many years ago who were past middle-aged by then, but had grown up in an asbestos-producing town in Quebec. Dad had worked at the mine. As was the norm back then, he would arrive home from work, sit for a bit and hug the kids before heading to change and wash up. It wasn’t known then that he was exposing the children to the asbestos fibres that travelled home on his clothes. Dad, and 3 of his 4 children - including one I looked after - ended up dying of mesothelioma, which is a specific lung cancer caused by asbestos.

Asbestos fibres are just the right/wrong size that they can be inhaled deep into the lungs, where they take up permanent residence and cause a chronic inflammatory state that can predispose to cancer. The delay between exposure and cancer can be decades.

Y’know what is similar in size and shape to asbestos fibres? Ever wear a mask for a while and feel it get fuzzy on your mouth and nose? The first time that happened I assumed my cat had slept on my mask. Not so - it’s the fact that the mask is made up of small plastic fibres. Masks break down and these fibres are shed. Guess what happens when you breathe in with a mask on?

These fibres may be benign when inhaled. But there is no reason to assume that. It will be many, many years until those of us who were forced to wear masks for 2 years (or more! this may not be over yet!) will know whether plastic fibres have been living in our lungs, and increasing our risk of cancer or other lung issues.

This is not to mention that in the rush to produce billions of masks on short notice, it’s not like a lot of time went into health and safety standards. It was a free-for-all, with goodness-knows-what chemicals being used in masks. If mask wearing was rare and brief this might not be a significant concern. But during The Age of Mandates mask use was far from rare, and often prolonged. Will we see a new form of respiratory disease called “Mask Lung” emerging? Let’s revisit this in 20 or 30 years…

Garbage

Speaking of toxic chemicals, masks aren’t exactly environmentally friendly. Surgical masks are made from plastics, which are fossil-fuel products. The production of plastics is extremely dirty. We get around this in Canada by importing all our plastic sh… stuff from China. Problem solved!.

And then there is disposal. Masks are not recyclable. Some estimates say that the 7.8 billion of us on the planet used over 125 BILLION masks PER MONTH during the pandemic. If you do the math, if only 1% of those end up tossed on the side of the road, that’s 1.25 billion masks in trees, floating in the ocean, breaking down into microplastics, toxifying water supplies etc. And don’t forget even if landfilled, most things eventually work their way back into our groundwater.

Communication and Reading Faces

I’ve attended several “Effective Communication” sessions through the years, both in med school, residency, and part of ongoing med ed. (I know, I know - probably not working, right!) The importance of non-verbal communication is always stressed, including how a large part of meaning is conveyed through facial expression. The difference between being flat-out-serious and being ironic is sometimes conveyed only by a slight curl at the corner of the lips. There is a good reason that there are now dozens and dozens of face emojis. We all understand what they mean. Put a mask on them all, and they mean almost nothing.

In fact, we humans are EXQUISITELY wired to see and interpret faces. Believe-it-or-not, this attention to faces can be shown even before a child is born. (Interestingly, female fetuses are more attentive to faces than males, but that’s another discussion..) In fact, we are SO programmed to see faces, that we see them in everyday objects. (This is a phenomenon called pareidolia - which is interesting to read about).

Not exactly The Shroud of Turin, but pretty cool nonetheless..

There is some concern that reading facial expressions – very important for humans, and one of the differentiators of those “on the spectrum” of autism versus those who aren’t – is a skill for which the window of opportunity for learning may close at a certain stage of brain development. Is a certain cohort of kids doomed to go through life without this ability properly developed? What happens to kids who don’t see faces regularly and learn to interpret them? Take a minute to watch this video. Even though it’s a bit upsetting it’s worth it. Thanks to Matt Aldred for pointing it out.

Language acquisition

Not seeing faces has a profound effect on young children who are in the stage of life where they are acquiring language skills. Kids mimic and learn language not just by hearing sounds, but by watching mouths move. Observe how your mouth moves with saying the letter “D” versus “B”, as in “DECK” versus “BOO” or the “N” in “Nancy” versus the “M” in “Mary (give it a try, unless you’re reading this somewhere in public). We do these things unconsciously as adults who have already acquired our language, but kids need to learn it. That learning process is undoubtedly impacted by being surrounded by people in masks.

There is a 3 year old in my extended family who is speech delayed. Mask mandates have been in place through the whole time of his life where his brain is maximally open to language acquisition. Anyone with a functional brain will understand this has to have an impact. Perhaps he would have had some troubles anyway. But would they have been milder? Or would he have had no difficulty at all?

We are born pre-wired to learn certain things at certain times. Language circuits wire early. That’s why a kid who spends her pre-school years around 4 different languages has learned them for life, whereas those of us who “essayer d’apprendre une nouvelle langue” late in life struggle so much. Will these speech-delayed kids we have created ever be fully functional? Only time will tell.

Hearing impairment

As per wikipedia, the font of all knowledge (just don’t trust it for politics!):

“Although lip reading is used most extensively by deaf and hard-of-hearing people, most people with normal hearing process some speech information from sight of the moving mouth.”.

Particularly for the hearing impaired, the “age of masking” has been an age of “what they hell did that person just say?”. I recently had an elderly patient return from a specialist appointment that I had sent them to. When I asked “What did they tell you?”, my patient replied “I have no idea - they had a mask on the whole time so I couldn’t understand them”. I just hope the specialist didn’t tell them “make sure to stop your blood thinner or you could bleed to death”.

As an aside, I also know numerous people who lost their hearing aids taking masks off and on. It sounds minor unless you know how much an average hearing aid costs these days. (Maybe this whole mask agenda is being pushed by “Big Audiology”!)

Not everything that can be counted counts, and not everything that counts can be counted

This famous quote has been attributed to Einstein. Like many quotes attributed to him he didn’t actually say it. But it’s still a very profound comment.

What do we lose when we don’t see faces? Seeing a smile can raise oxytocin, the “love hormone” and decrease stress hormone levels. But even without measuring hormones, we all understand the joy we get when someone smiles at us. Or the fun we have making ridiculous faces to make a baby laugh.

One of my wonderful colleagues “F” died of cancer last year. She had been regularly in and out of the hospital in her last 2 years of life, getting various treatments, transfusions, and blood tests. F was admitted to hospital for her final days. One of our newer nurses often cared for her, and they got along well. They had met perhaps a few dozen times. The day before she died F asked the nurse: “Do you mind taking your mask off?”. The nurse knew she was breaking protocol but did as asked, and asked F why. She said “I’ve known you for more than a year and I’ve never seen your face”. The nurse smiled, and F broke into a huge grin and said “You have such a BEAUTIFUL smile!”. In our current climate of “Only COVID Counts”, that story counts for nothing. I think it counts for a lot.

Conversely I helped care for a palliative care patient. Even in his last days, his family was so scared to transmit COVID that they kept their masks on at all times, even at the bedside. He was confused and had trouble recognizing people. It is sad to think that the last times he looked up and saw a face, it was masked. He may not have recognized them; he likely didn’t know that those who loved him were there with him.

General PITA

Many of us consider masks a pain in the ass. Were you ever carrying a big armload of heavy items when your mask pops off your ear, then get chewed out by a security guard for not having your mask on properly? Did you lose your 3000 dollar hearing aid in the snow when taking your mask off? Have your glasses fogged up because of the mask, you couldn’t see, tripped and broke your hip? These are all real stories.

In Sum

In my previous articles on masks I think I’ve established that if they do anything at all to reduce COVID transmission, it is minimal. Prior to COVID every medical decision (including those of public health) considered both benefits but also risks. Decisions on mandates were made assuming masks were completely benign - but that assumption was wrong. You CAN be too careful when trying to reduce COVID if you cause morbidity, mortality, and misery with your attempts.

A proper public health response would have been wise, non-political, and balanced. It would not have been arrived at by jumping to a conclusion, and from there onto a political bandwagon which used shame to denigrate anyone who criticized masks.

Is wearing a mask a sign of respect for others, or is it a sign that you are scientifically illiterate? We can agree to disagree, but I feel strongly that a medical officer of health cannot decide what is right for an individual in every circumstance. Like so many other things during COVID - gathering in groups, going to work or a gym, deciding whether to be vaccinated or not - masking should be a personal decision, made by individuals based on their knowledge and values. I choose NO.

Next up: Hypocrisy, Ridiculousness, and Masking. How masks were part of how COVID melted our brains