Masked faces: The new normal and COVID-19
It sseemed like eons ago when wearing a face mask was considered weird. At least in this part of the world. The Chinese and South Koreans appear to be ahead of us because they’ve been masking their faces since the 2002-2004 Severe Acute Respiratory Syndrome (SARS) global epidemic. Severe Acute Respiratory Syndrome is caused by SARS-CoV. The present pandemic is caused by another respiratory virus; SARS-CoV-2. Masks were also popularly worn in India and China against air pollution. That was then.
Therefore, it’s no wonder that people from East Asian countries are donning face masks without any fuss. Back to 2020 under the cloud of COVID-19, in any part of the world it’s now anomalous if you are not wearing a face mask in public spaces. The face masks could be surgical or textile grade. Scarves and handkerchiefs are also being used although they are not as effective as face masks. You can also be denied entry to some offices and public transportation if you are not wearing one although the enforcement has waned in several countries including Nigeria.
Unsurprisingly, objectors from the West, particularly the Americans, Australians and some Europeans have vigorously protested against the wearing of masks. Their grouse is that it infringes on their freedoms and rights. Back in July, Israel also saw protesters against the mandatory wearing of masks. On the 18th of September, Israel instituted a second country-wide lockdown because new COVID-19 cases were spiraling out of control with six thousand confirmed cases per day in a population of 9 million people. Meanwhile people from East Asia mainly China, Taiwan and South Korea are happy to adorn their faces with the covertures without much ado.
Expectedly, countries that have protested against the compulsory adornment of the innocuous symbol of compliance to social responsibility have seen the number of confirmed cases rise. These countries are now on the brink of a second wave of the pandemic. Some have once again become epicenters of the disease, recording more than ten thousand new cases per day like on the 12th of September in France and more than thirteen thousand five days later. By the 18th of September, the global number of confirmed cases was over 30 million. More than half of this number was from three countries combined; The USA, India and Brazil.
While no one in Nigeria is actively carrying placards or picketing against the wearing of face masks, most of our people have actually stopped wearing them. In fact, if you walk in some public spaces, you might think the mask has never been invented. The lone believer in social responsibility that wears one is considered an overachiever because of the erroneous belief that the virus is no longer in Nigeria or just the user-fatigue of our people.
In some countries, you can be fined for being in public without wearing a face mask. However, while wearing of masks protects us against the virus, it blocks about 70 percent of our faces. Now, humans are sociable beings not counting the odd introverts here and there. Communication is mainly verbal but eighty percent of that communication is seen on the face and is non-verbal. Hence the face mask has invariably cut off that part of non-verbal communication.
Imagine a mother calling her ten-year-old son while he’s playing outside. The child says, “Yes, mum.” But if you can read the child’s facial expression you can see from his face that he is not pleased at being called away from his friends. Take the lady that is accidentally stepped upon by a man in a hurry. The man apologizes but you can see from the lady’s face that she’s irritated. All these non-verbal cues become lost when wearing a mask. You also get to miss the beaming smile on a child’s face after her parents just bought her favorite toy. Then there are those who depend on lip reading. Suddenly, that part of communication has been cut off. Although we have some innovative fabric designers using transparent plastic over the area of the lips so that lip readers are not left out altogether. Even so, specialized face masks dedicated for lip readers are not easily accessible.
Wearing of the mask is also psychologically beneficial to us. As humans, we want to assail our own personal fears about the virus and one of the least we can do is to don the facial mask or a face shield. Some are even donning both a face mask and a face shield. Wearing of a face shield without a face mask is not as protective as wearing a face mask alone or as wearing a face shield with a face mask. Wearing of a face mask helps in slowing down the spread of the virus by as much as 40 percent. Since we are dealing with a virus with a long incubation period and asymptomatic for the most part, prevention is the best way to go. Further, the novel coronavirus appears to have ambitiously acquired a permanent residency visa on the global stage, so we have to learn to live with it, around it and ultimately defeat it.
It’s not enough to wear a face mask, but a few want to make a bold statement. Some are printing face masks with their favorite cartoon characters, or texts on some attitudinal changes like “Where is the money?”. Some are making political statements like wearing the names of African Americans killed by police officers on their masks. Professional athletes like Sloane Stephens, Naomi Osaka, Frances Tiafoe and The Toronto Raptors have put on masks with words or letters referencing, “Black Lives Matter”, “BLM”, “No Justice No Peace,” “George Floyd” and names of other African Americans killed through police brutality. Politicians have also worn face masks symbolic of Black Lives Matter. The more patriotic amongst us wear their national, state or tribal colors on their mask. International fashion designers are making profit from the moment and selling their fabric face masks for as much as 80 Euros. They’ve got buyers because they sell for twice that amount on some electronic platforms like e-bay. You can also get a good face mask for between 100 and 200 Naira. In supermarkets, it could be as high as 900 Naira.
While most people are not bothered about making a statement, they end up wearing it on their chin, or just below the nose and some just wear it over one ear. And some, roughly tuck it away in their pockets and magically produce it in case they are asked to wear it. These mask wearers seem to be donning a mask to prevent harassment from security forces. Understandably, the warm weather makes covering with a face mask unbearable. Some disposable masks have been worn repeatedly and you can see the dirt on the outside increasing the risk of infection. It’s difficult to ask such wearers to replace them because of affordability. Similarly, some fabric masks are worn repeatedly without washing and become a source of contagion. If our local production of masks can increase, then the price would come down. With sustainable and consistent health education messages targeted at specific populations we can achieve the right attitude to wearing of face masks.
Not all fabric face masks are the same. The materials used in making fabric face masks must be breathable and must have filtering capabilities. Cotton fabrics are best for making face masks. The higher the quality of cotton fabric used, the higher the filtering capabilities. A quick test to check the filtering capabilities of your cotton mask is to hold it to the light. If you can see the warp and weft yarns of the fabrics; the crisscrossing fibers of the fabric, then the filtration capabilities are in doubt. The tighter the weave, the better the filtration capabilities.
The thread count in cotton is the number of cotton threads woven into one square inch of fabric. The higher the thread count, the higher the filtration properties and the softer the cotton feels on the skin. Very soft cotton bed sheets have a high thread count. Cotton and denim fabrics with a thread count of 120 or higher will filter out 90 percent of large particles and 24-29 percent of small particles. You can increase the filtration properties by lining the face mask with a lighter cotton fabric. Cotton fabrics with thread count of 200 or higher will filter out much more. Canvas fabrics are thick cotton material about 0.4-0.5mm thick filtering out about 84 percent of large particles and 19 percent of small particles but have poor breathing capabilities. The type of cotton shirt materials worn by athletes have poor filtering capabilities.
Masks made from nylon fabrics are very poor at filtering out particles and also make it difficult to breathe. Masks made from wool can actually increase the entry of particles by trapping them in their fibers. Microfiber and linen have poor filtration capabilities.
Wearing of fabric face mask does not mean the coronavirus or any virus will not pass through but it will reduce the ultimate, final viral load that passes through. And in case the mask wearer is already infected, it would reduce the chances of spreading the virus.
Continuous wearing of tight-fitting face masks like N95 can cause reduced oxygen levels because N95 masks fits tightly across your face and you’re rebreathing your own exhaled carbon dioxide. N95 facemasks should not be worn for so long that it causes a reduction in the user’s oxygen. N95 masks are part of personal protective equipment and are not meant to be worn for prolonged periods. Fabric face masks made from materials with poor breathing properties will also cause a reduction in oxygen levels. The tightness of the face mask around your face, the breathability of the material from which the mask is made from, whether surgical or fabric grade and the status of the respiratory system of the user can affect the wearer’s oxygen levels.
Ironically, the tighter the face mask is round your face, the lesser are the chances of a virus particle getting through. Ideally, we want to wear our mask snugly around our faces but we must strike a balance between fitting the mask tightly round our face and our need for oxygen.
Prolonged wearing of face masks like we have had to do during this pandemic would also have some yet-to-be discovered psychological effects. It would take years before we can tell what the long-term psychological effects of mask-wearing will have had on us especially on very young children that have just started secondary socialization. These are the children who recently started school. Masks should be changed daily even if they do not appear to be dirty and must never be shared. Fabric masks that have been worn should be washed daily. Fabric masks should be washed in gentle soaps that lather and spread under the sun. The coronavirus has been known to be “killed” by the sun’s heat. Constant washing of fabric masks will weaken the tightness of the cloth fibers thereby reducing their filtering properties. Therefore, it is good to change your fabric mask after a few months or after several washes.
We’ve had the virus with us for about nine months now. We should not become mask-fatigued because the virus has not bidden goodbye. Wearing of our face masks is a sign of personal social responsibility. We protect ourselves as well as anyone around us. We have three things that we are personally responsible for; washing of hands, keeping social distance and wearing of masks. Washing of our hands and social distancing may not be totally under our control. The availability and accessibility of water to wash our hands can depend on resources beyond our control. Social distancing may not be totally under our control because while trying to keep our distance, crowds can meet us where we are. However, wearing of face masks for the most part depends on our own control and shows our personal responsibility.
Well, whether you’re wearing a face mask to make a statement or you’re wearing it to assail your fears, consider how you remove and dispose of that mask. You must carefully remove the face mask once worn and dispose properly if it’s the disposable type. Dispose in a grocery or trash bag and make a knot with the trash bag so that the mask does not end up being “recycled” by garbage collectors. You can cut off the strings of the used disposable masks to make sure it will not be worn by other persons. Since we are to wear our masks daily when going to public spaces, it is a good idea to have at least two fabric face masks.
Disposed surgical and fabric masks are being seen everywhere like the empty pure water bags that have become ubiquitous in our environment. As we are in the rainy season, these ill-disposed masks may end up clogging our waterways complicating the flow of rain water that could end up as floods. While trying to take care of one problem, let’s not create another. We all have to get accustomed to a new normal so we can as well get used to wearing face masks and make some beautiful statements while at it.
This is not the time to become user-fatigued in mask wearing. It’s difficult to keep all the COVID-19 protocols because we all cherish our freedoms but we need to collectively look at the end result of our behaviours to stop the virus. We need to be personally responsible in maintaining the COVID-19 protocols especially mask-wearing, social distancing, respiratory and hand hygiene.
When three-quarters of the global population was on one form of lockdown or the other, Sweden with its population of 10 million people did not go on a severe lockdown. There was a mutual trust between the Nordic country and its people. The Government of Sweden refrained from mandatory lockdowns and mask-wearing. Rather, it depended on the people’s personal social responsibility. It only recommended that they increase their hand and respiratory hygiene, work from home and keep social distancing. The wearing of face masks was voluntary and those who wore them did not do so out of compulsion although it was not worn by all. The schools were open for children less than 16 years old. The universities were closed. It also banned gathering of more than 50 people. The point of the voluntary wearing of mask till now meant that they were intrinsically motivated as opposed to extrinsic motivation.
When a behaviour is intrinsically motivated and not forced, it is more likely to be sustainable over long periods. When behaviors are extrinsically motivated like governments making face masks mandatory with insufficient health messaging, they are not sustainable. However, with effective health education and consistent messaging, extrinsic motivation can be increased and the desired mask wearing behaviour achieved. It is difficult to maintain extrinsically motivated behaviours. If we look at countries that had the severest form of lock down, in the first wave of the pandemic, those countries are now having inklings of a second wave with new daily cases in some countries being more than thirteen thousand.
An explanation can be found in human behaviour. Human behaviour that was extrinsically motivated with inadequate health education was not sustainable such that as soon as the lock down was relaxed, people consciously or unconsciously went back to their old ways and threw away all COVID-19 protocols. They unconsciously rebelled against the many restrictions that had been imposed on their liberties most especially the mask wearing and social distancing.
Amongst the Nordic countries Sweden now has the lowest number in daily cases. However, during the first wave of the pandemic compared to its neighbours, it had the highest deaths. More than half of those deaths were from the elderly care homes; five times higher than those in Denmark. This blight in the Swedish approach also appeared to be disadvantaged to the weak. It invariably plays out for survival of the fittest; the old people died while the younger ones survived.
My analysis of the Swedish approach has shown that the alien behaviour of mask wearing is not sustainable on the long run but mutual trust between the government and the governed has allowed the Swedish to voluntarily choose to wear or not to wear face masks. It has also reduced the probability of overwhelming their hospital beds. In this month of September, while many countries in Europe are having a second spike, Sweden has actually had a drop in the number of cases with only 1.2 percent of its 120,000 tests being positive by the 9th of September. The 1.2 percent is a good pointer to the control of the disease. For COVID-19 to be considered under control, less than 5 percent of test results must be positive.
One possible explanation for the dip in the number of cases in Sweden could be herd immunity. Since some of the Swedish were not wearing masks at the peak of the pandemic, the infected ones amongst them were able to infect others and over several months, a moderate level of immunity had been achieved in the population. Without actually testing their blood for antibodies to SARS-CoV-2, one cannot definitively confirm that there’s herd immunity but it appears to be so. Antibody tests examines the blood for antibodies indicating a previous infection. Antibodies are proteins present in the blood. The presence of antibodies is a marker informing us that the person has been infected and most likely recovered from the novel coronavirus. Antibody tests are different from diagnostic tests. Diagnostic tests normally determine the presence of the virus indicating an ongoing, present infection. Nasal swabs are usually taken for diagnostic tests. The daily numbers of confirmed cases presented by NCDC are results from diagnostic tests.
Similarly, in Nigeria, most people stopped wearing their masks some months ago. And around the same time, the number of new cases began to drop from 603 on the 4th of July to 354 on the 6th of August and 189 new cases on the 19th of September. The drop in the number of new cases could also be because we’re not doing enough tests. Although the number of tests conducted on 19th of September and 4th of July were approximately the same; 2,850 tests on 19th September and 2,933 tests on 4th of July. On the 6th of August, 3,835 tests were conducted. The number of confirmed cases decreased markedly from 603 on 4th of July to 189 on the 19th of September. And it could be that most people have asymptomatically had the disease, recovered and never even knew they had had the disease. It’s also true that those whose immunity were not strong enough were taken down by the disease.
However, it’s also possible that these asymptomatic persons are infecting unsuspecting people. Could we possibly be having a herd immunity or are there other factors to consider? These are all possibilities we’ll never know unless the blood of random persons in the cities are taken and tested for SARS-CoV-2 antibodies. We don’t know definitively if we’re having a herd immunity, but we do know undeniably that wearing of masks will protect us so we should intrinsically motivate ourselves so that without much effort we can once again begin to wear our facial badge of responsibility. The only true test of one’s immune system is if one gets the disease and survives but it’s not a path we want to take. Therefore, our governments can ginger up and extrinsically motivate the people with consistent and sustainable health messages. And we too should intrinsically motivate ourselves to return to wearing of our masks. Who knows? Post pandemic we can start celebrating a “wear your face mask day” in commemoration of the pandemic. No one knows when that day would come, but we must remain hopeful.
Obilade, a medical doctor and an Associate Professor of Public Health wrote from Abuja.
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