Learning to Live with Masks

First published in the NASGP Newsletter in August 2020

Masks are going to be with us for a long time to come. We’d all better get used to them.

Masks are uncomfortable, your glasses steam up, they muffle sounds and restrict facial expressions. It’s difficult to know if you are wearing them correctly. You can’t eat, drink or smoke wearing a mask. Or kiss.

Are they worth the hassles?  When covid-19 reached England, before there was any experience to go on, some doctors invoked the precautionary principle: faced with a serious harm, in the absence of evidence, it is advisable to take a possibly effective action with few downsides. Some sections of the populations – people of my age, for instance – accepted the argument. But many didn’t.

If it could be proven that a mask protects the wearer, doubtless far more people would choose to wear a mask. Such evidence may be forthcoming, but meanwhile, it is worth bearing in mind that the idea that Real Britons Don’t Wear Masks doesn’t stand up to history. Londoners sheltering from the Blitz in underground stations didn’t see masks as demeaning; they all wore them to protect themselves from epidemic infection.

In 1940 you heard the bombs and saw the damage they did. Since then, social solidarity has given way to social media. Individualism reigns. It is easier to discount an unseen threat. You can see yourself as an exception – too young, too healthy, in the USA too Republican – to the generality of the population.

“I thought it was a hoax. I was wrong”.

How sad that some people are prepared to abuse and assault others, even kill, for the ‘freedom’ not to wear a mask. Americans – young as well as old – evoke conspiracy theories or respiratory physiology (incorrect) or evidence (incorrect) and call on their federal constitution and their God-given right to breathe freely to justify refusing to wear a mask. Trump, god, snake oil will keep them safe.

Except they don’t. In Texas, a 30-year-old who had been to a corona-party said before he died, “I thought it was a hoax. I was wrong”. 

Now we know that asymptomatic people can transmit covid, and people are going out more, so a measure which provides even a marginal barrier to transmission has to be worthwhile. And it’s good publicity: it’s a signal that you are aware there is a public danger. To some people’s surprise, yes, you do have to wear a mask even though you’re on holiday. Masks have been de rigeur for months in countries like Spain. Coming back home, holidaymakers discover that, finally, England’s government has caught on. Masks must now be worn in shops and public transport. But when those in authority have wasted months dithering, rubbishing masks and breaking their own rules, it’s a bit late to expect everyone to obey a law that is hard to enforce. 

Engaging the public is an uphill task. At the Venice carnival a mask is alluring. For terrorists or bank robbers, masks are tools of the trade. If you are a shaman, a mask adds to your mystery. For super-heroes like the Lone Ranger or Spiderman, masks are an essential adjunct to their image. The Chinese wear them to keep warm. If you are a surgeon, cynics would say you wear a mask to stop your expletives or gold crowns falling into the patient’s wound. If you are in your local high street, a mask is just a nuisance. But with a decent public campaign, peer pressure and masks that are glamorous or fun, it can become taken for granted. Masks now feature on the fashion pages, and Nicola Sturgeon’s tartan version is already a must-have north of the border.

On our early morning walks in Regent’s Park, we are almost the only people without a dog, a fit-bit or ear buds. And two of the few with masks. But each day the mask count is increasing. Yesterday, out in Kilburn, not a hotbed of conformity, most people were wearing masks. Women wearing a niqab say they now feel much less conspicuous in public (though they still need a covid masks as an Islamic face covering is too flimsy to keep the virus contained).

Even if you and your society accept masks, the ethical dilemmas aren’t over. Is your mask effective? Was it made in a sweatshop? If not, can a poor person afford it? How can discarded masks be safely disposed of? And what about those for whom a mask makes verbal communication almost impossible?

Twelve million people, consciously or unconsciously, use lip-reading as an aid to understanding other people’s speech. The Government’s website includes among the exceptions to the legal requirement to wear a mask those who accompany people who rely on lipreading, and, anticipating that members of the public may challenge people who aren’t wearing masks, has produced an exemption card. This can be printed off or downloaded onto a smartphone from Action On Hearing Loss website.

It might seem that the Deaf who communicate by signing have an advantage. Possibly, although, as anyone who watches signing can see, as with spoken language a lot is communicated by facial expression.

Putting on PPE has revealed to many older doctors the uncomfortable reality of their own impaired hearing. Consultations between a GP and a patient, if both are in their 50s or 60s, and both are masked, is challenging. Video consultation has its limitations: even when the connection is good it blurs the subtleties of voice and body language, and the effort of trying to detect and fill in the gaps is tiring. But it is more satisfactory than struggling to communicate through masks, especially if, like most locums, you don’t know the patient.

Masks with clear panels aren’t the perfect solution, but at least lip-reading is possible. Thanks to small enterprises, such masks are widely available, although procuring a medical-grade clear-panel mask may be more difficult and full face shields are expensive. But GPs should make sure they have a clear-panel mask or a face shield to use when seeing patients who are hard of hearing.

Masks are going to be with us for a long time to come. We’d all better get used to them.

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