ON July 15 in Kuching, a restaurant employee was allegedly slapped by a customer who had wanted to enter the premises without a face mask. A Chinese daily reported the woman and her male companion allegedly kicked up a fuss, saying ‘other restaurants had no such rules’. The male companion berated onlookers and slapped the staff member for ‘being a busybody’. The staff member was just trying to calm things down. The incident was captured on the shop’s CCTV.
Private freedom versus public health
You might have seen videos of unmasked young women in the USA throwing groceries and spewing obscenities after being asked to wear face masks in shops. These fits of apoplectic meltdown followed rules in various US states requiring masks in public places due to the surge in Covid-19 deaths and cases. As of July 9, the USA (population 328 million) had 3.24 million cases and 136,000 had died compared to Malaysia – population 32.7 million, 8,696 cases, and 121 deaths. A study estimates that if 80 per cent of Americans wore a mask, the Covid-19 infection rate would drop to 8 per cent of its current rate.
The belligerent attitudes behind the refusal of anti-maskers to wear masks are well illustrated by three cases on YouTube. In Dallas, a woman shouted as she threw her grocery items all over the floor before stomping out. In California, when stopped from entering a shop, a woman swore and added, “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 equates wearing face masks to wearing underwear. “I don’t wear them for the same reason – both need to breathe!”
Whose rights should prevail?
So should it be the personal freedom to choose or the rights of others to protection from the consequences of that individual’s choices? A person is free to drink, but not free to drive after he has drunk above the legal limit. Smoking is a personal choice, but where you can smoke is not your choice in public enclosed or prohibited spaces.
This ‘to wear or not to wear’ conflict reminds me of the 1980s when, as the divisional medical officer in the then Third Division, I set up the first government STD (Sexually Transmitted Disease) evening clinic in Sibu, to provide discrete regular screening and treatment for commercial sex workers. Prostitution was illegal but a booming business when loggers came to collect their pay and travellers 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 gonorrhoea blinding baby’s eyes.
To reduce community transmission, free condoms were issued to the sex workers to protect them from reinfection. This did not work because invariably their clients refused to use them. The message ‘please wear condoms to protect the sex worker or your partner’ did not work. We had to focus our health promotion on raising awareness. “HIV kills. Use condoms to protect yourself, whoever the sex partner is, however young, however ‘clean’.”
The client was free to choose between knowingly exposing himself to a 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 knowledge also 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 his sex partner, transmission to the spouse and the unborn child continued. Hence the need for a mandatory, universal 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.
Like condoms, masks protect the wearer from infected contacts’ secretions. They also block to some extent the infectious droplets from the infected wearer, and reduce the contamination of the fomites and environment. It is a win-win situation when everyone wears masks.
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 sceptical and uncooperative.
Despite the successful capping of Covid-19’s spread in East Asian countries where the public wearing of masks is universal, WHO refused to endorse it until June 5.
In its April guidelines, the WHO had said there was no evidence that wearing a mask by healthy persons in the community can prevent infection with respiratory viruses and that 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 healthcare who need them most, especially when masks are in short supply.”
However, on June 5, the WHO revised its guidelines to encourage public mask wearing based on research that people can be highly infectious in the few days before they show symptoms (presymptomatic) and that some infectious people never show symptoms at all (asymptomatic).
The WHO advises governments to encourage their citizens to wear masks as part of a comprehensive approach to suppress Covid-19 transmission in the following situations.
1. Source control to prevent spread from an infected wearer and prevention to protect the healthy wearer.
2. Where there is community transmission and limited/no capacity to implement containment measures (contact tracing, testing, isolation, and care for suspected and confirmed cases) or those working in close contact with the public (eg social workers, personal support workers, cashiers, teachers, bus drivers)
3. People who are immunocompromised or with comorbidities (cardiovascular or cerebrovascular disease, diabetes mellitus, chronic lung disease, cancer), and those older than 60 to 65 years of age should wear medical masks.
4. Where individuals are unable to keep a physical distance of at least one metre or in places with high population density (eg refugee camps, dormitories or public transportation).
5. Availability and costs of masks, access to clean water to wash non-medical masks, and ability of wearers to tolerate effects of wearing a mask will affect the type of mask used: medical mask versus non-medical mask.
Individual ‘mouth and nose shut down’ (mask) is cost-effective and less socially destructive than locking down whole communities.
On July 7, the director-general of Health said that 70.2 per cent of the total 8,674 cases were asymptomatic, while 29.8 per cent were symptomatic. With this large proportion of asymptomatic spreaders, and the current resurgence in community and imported cases, the freedom of personal choice is no longer about to mask or not to mask.
It is about how we as a society can help those who may have difficulties sustaining the long term buying of medical masks. Actually, the use of 100 per cent cotton DIY cloth masks is a good option in non-medical, lower risk settings. Rather than exempting some disadvantaged students from wearing masks and putting teachers and the other children at risk, alumni or parent-teacher associations could make in bulk, locally sewn face masks to sell at cost as part of the school uniform.
No child, whose parents for whatever reason are unable or unwilling to provide masks, should be left feeling ostracised without a mask. It is financial suicide for schools (and any country) to provide ‘free’ masks in the long term to all staff and students. No one should expect free masks, except the truly needy students. Teachers are well placed to know who they are and can quietly provide them with a few cloth face masks for wash and reuse. Students who can afford to can wear whatever masks, their parents may choose. Face shields should be an addition, not a replacement for face masks.
Teachers in the high-risk group (obese, diabetic, immunocompromised, medical conditions, above 60 years of age etc) could slip a surgical mask between the layers of the cloth mask for added protection, so they can reuse the surgical mask. Perhaps we can protect our teachers in the high-risk group by assigning them to online classes rather than face to face classrooms. For this season.
There should be no apologies for turning sick students (with or without fever) away at the school gates, preferably before parents drive off. Children are usually more honest than their parents so it is always good to ask them how they are first, rather than the adults.
Dr Tan Poh Tin is a paediatrician, public health specialist, associate professor (retired), and medical disaster relief volunteer whose life mission is ‘doing good, healing all’.