Today’s looming disaster

Where I live in Japan mask-wearing is now pretty much universal – almost no one goes out in public and to see someone without a mask on in public is a kind of shock. The economy reopened after lockdown, in Tokyo, on 23rd May, on which date the number of cases had dropped to 5. Today the Tokyo Governor’s office released the daily update on COVID-19 (pictured above), and we have now returned to 107 cases, with the 7-day smoothed average hitting 65. Depending on how charitable you’re feeling that’s either a 21-fold or 13-fold increase in cases in 5-6 weeks. At its most charitable then we can say that cases have been doubling every 7 days. Today’s peak of 107 cases comes pretty much 5 days after the Tokyo government allowed bars and night clubs to reopen. All of the personal measures we have been asked to adopt – maintaining social distancing, wearing masks in public, and reducing our social interactions, have amounted to a hill of beans. In particular I think mask-wearing has been a completely useless strategy, and worse than that, I think the misguided possibility that widespread mask use will prevent transmission has led many countries to take unnecessary and stupid risks with reopening their economies. This is particularly tragic in the case of Tokyo, because Japan had a very good early response to the epidemic and Tokyo was down to just 5 cases when the government ended the lockdown early. One or two more weeks of actually effective strategies would have ended the epidemic in Japan but instead the government chose to begin reopening the economy early and rely on personal behavior change to prevent its spread.

This was a disaster, and anyone who understands public health should have seen how disastrous this idea is. Infectious diseases are never stopped by individual behavioral change or personal responsibility: they are only ever affected by social changes and policy. We know this from 40 years of responding to HIV, and in this blog post I want to explain how the terrible failures of the early response to HIV should have served as a warning about relying on barrier methods and personal responsibility for preventing the spread of the disease. What is happening in America was entirely predictable based on 70 years of public health knowledge, and it’s a depressing indictment of public health policy-makers that they did not do more to stop it.

The narrative of mask use and economic reopening

First let us examine the history of moves to reopen economies from lockdown and the heavy dependence on mask use to achieve this reopening. Some academics at Stanford University recommended mask use as a way to prevent further shutdowns after reopening in late April. In an April 22 news report the governor of Louisiana made clear that mask use was a key part of his reopening strategy:

It’s just like opening a door for them, or saying good morning or whatever it’s being kind and being courteous, and when others wear masks they protect you. So we’re all in this together. When we all wear masks we’ll effectively protect one another which is why I’m calling upon Louisiana to mask-up.

The governor of Georgia suggested mask use could help with reopening that state in mid-May. The website lists individual state’s reopening plans and makes clear that almost every state mandated, requested or advised face covering and mask use as a form of protection in sites that were considered high risk but were now slated for reopening. For example California has moved to Stage 2 of its resilience roadmap, and recommends

Crowded settings increase your risk of exposure to COVID-19. Wear a face covering or cloth mask, stay 6 feet away from others, avoid touching your face, and wash your hands when you get home.

Rather than limit access to crowded settings, the government simply advises people to cover themselves and take individual actions to protect themselves and others.

On 1st July Louisiana saw 2083 cases, a five-fold increase on the number it saw on April 22nd; Georgia saw 2,946, probably a 4-fold increase on mid-May; and California saw 6,497, a 3-fold increase over the number it saw when it moved to stage 2 of its “resilience roadmap”. All these states are now at the inflection point of a major upward surge in cases. All the personal responsibility and individual actions they advised to prevent the spread of the virus have done very little to protect their citizens from this epidemic.

The scientific evidence for masks and social distancing

On 1st June the Lancet published a systematic review of the evidence for face masks as a protection against coronaviruses. It found only 3 studies with quantifiable evidence of the effect of masks in non-health-care settings, and pooling the results of these studies found a 44% reduction in risk, which is shown in the figure above. While mask use in health care settings has a very large protective effect (70% reduction in infection, with a narrow range of effect from 57 – 78%), it is nowhere near as effective in non-healthcare settings, and there is little evidence to support it. This is why at the time of writing the CDC still does not suggest there is any evidence for the effectiveness of surgical masks, and why the WHO was unwilling to recommend their use during the early stages of the epidemic.

Why is there so little evidence and why would masks not work in public when they’re so effective in hospitals? The lack of evidence is because most countries don’t use masks in any disease-prevention way in public, and so it is very hard to conduct studies. The lack of effectiveness probably arises from the fact we aren’t trained to use them: we don’t know how to take them off properly or even which side to place on our face, we don’t treat them as single-use items, we often don’t carry spare ones so we need to lower them in public to eat and drink and then raise them again, they get damp and become ineffective because we wear them too long, we wear the wrong masks for settings with high infection risk, and we don’t combine their use with the regular, intensive and disciplined hand hygiene that medical personnel use. I have recently spent a week in hospital during lockdown for surgery, and the aggressive and disciplined pursuit of hand hygiene was noticeable and completely different to community life. If you don’t know how to use a mask and don’t practice proper hand hygiene it is not much use. Here are some examples of mask use I have seen in Japan, when commuting or wandering my suburb (in a mask):

  • A man pulling his mask down on the train so he can pick his nose and wipe it on the poles people hold
  • People wearing their mask pulled down so their nose is uncovered (so common)
  • People folding their mask up and putting it in their pocket or a bag
  • People putting their mask on a table or other unwashed surface and then putting it back on again
  • People putting their mask on backwards
  • People taking their mask off to use a shared microphone in a public meeting
  • People wearing masks to karaoke and taking them off to sing

It is of course also impossible to maintain social distance on commuter trains in Japan. I have also noticed that everyone complains that when they wear a mask their breath steams up their glasses, which means constantly fiddling with the mask and wearing it too loose. If your breath is getting out of your mask rather than through it, you are not protecting anyone and you aren’t protected.

Even if masks were 90-100% effective though, we still know that a strategy of mask wearing will not work. We know this because we tried the exact same strategy for HIV and failed.

The failure of barrier methods for HIV prevention

HIV first entered western consciousness in the early 1980s. It was initially identified in men who have sex with men (MSM) in America but the pandemic really took off in heterosexual people in sub-Saharan Africa, probably because it was already widespread by the 1980s. The first treatment was introduced in 1987 but the first really effective treatments, highly active antiretroviral therapy (HAART), were only introduced in 1997. In the early 2000s HAART was discovered to reduce the transmissibility of HIV, meaning that people taking HAART were less likely to pass the infection to others even if they were having unprotected sex. This discovery came at about the same time as George W Bush introduced PEPFAR, a massive program of HIV testing and treatment in sub-Saharan Africa, and this widespread testing plus availability of a treatment that could render people non-infectious led to some gains in the battle against HIV.

Now that HAART is available the fight against HIV is almost exclusively based on testing and treatment, but until the mid 1990s the only effective strategy we had for prevention was condom use. Condoms are 90-100% effective in preventing the spread of HIV, and we ran aggressive condom promotion and distribution schemes in the 1980s and 1990s to encourage safer sex and prevention of HIV. Despite dumping huge amounts of money and resources into these programs in the 1980s and 1990s HIV continued to spread rapidly in both heterosexual communities in Africa and MSM and some other at-risk communities in the rest of the world. Condom promotion strategies did not work to prevent the spread of HIV even though we knew that they were highly effective tools for prevention. Barrier methods were all we had – our entire strategy was based on behavioral change and personal actions – and it failed miserably.

The same is also true of all the other STIs: gonorrhea, chlamydia, and syphilis are all still widespread in heterosexual and MSM communities despite the sure knowledge that they are easily prevented by condoms. Indeed, these diseases are much more prevalent in communities that have easy access to condoms but poor access to testing and rapid treatment, such as indigenous populations in Australia or very poor communities in the USA. It is the structural factors of access to testing and treatment that determine the spread of these diseases, not the ability of individuals to take individual action to protect themselves or others.

Why is this possible? How did this program fail so monumentally when the individual preventive action it was based on is so well known to be highly effective? The reason is that sex is a social act, and social acts are mediated by complex social forces that it is difficult for us to navigate and control on our own. When people have sex they choose to flout social rules, they don’t always plan ahead, they are sometimes under the influence of drugs or alcohol or in a rush or not quite sure of exactly what is safe. Power relations are common in sex and can lead to people not being able or willing to negotiate condom use. Just as masks interfere with the ease and enjoyment of basic social interactions, so condoms interfere with the ease and enjoyment of sex, and people sometimes choose not to use them for this and other personal reasons. People also often make judgments about who and what is “safe”, and make these decisions with partial information in very emotionally fraught circumstances. And of course if you want children – a fundamental consequence of and reason for this social interaction – you can’t wear a condom. And so HIV spreads.

There are communities where condom distribution has worked but this is rare. It was probably partially successful among MSM in Australia, but probably because the campaign to use protection and beat HIV was explicitly tied in with the campaign for rights for MSM. It has been successful among sex workers, but this is because sex workers have no social incentive not to use condoms and have powerful tools at their disposal to enforce their own protection, and this is only true in some communities of sex workers who are strongly protected by cultural, social and legal norms that give them the social power to control their sexual interactions. There are many communities of sex workers in the world who cannot negotiate condom use precisely because these structural factors are aligned against their personal protective choices.

In contrast, we can identify a group of people who are at very high risk of HIV but have very low rates and among whom outbreaks of HIV are quickly identified and shut down: porn actors. Porn actors have large amounts of completely unprotected and often high-risk sex with multiple partners regularly, but have low risk of HIV. This is because they work in an industry with rigorous, regular testing policies that ensure that HIV cases are caught before they can become widespread. This is an example of how high-risk behavior can be safe if it is regularly tested and treated, but low risk behavior (for example among heterosexual people in Africa) can be dangerous if it is forced to rely on personal protective actions without the support of a health infrastructure.

Against infectious diseases, social and policy actions are always more powerful than individual actions, because infectious diseases are a consequence of our social interactions, not our personal decisions.

The difference between strategies and individual actions

Public health strategies obviously always rely on individual actions: we need people to report symptoms, to attend clinics for medical care, to comply with test and trace strategies, and to cooperate with the health system. Many of these actions can be guaranteed to happen under the right circumstances because they benefit the individual: if you can afford care, getting care is good for you, so you are likely to do it. But any policy which requires people to do the right thing in a burdensome way runs up against a huge problem: many people do not want to, or are not able to, do the right thing. This is why states have to mandate seatbelt wearing and introduce random breath testing to prevent drunk driving: the action they request of individuals is burdensome and unpleasant, so people won’t do it if they aren’t forced. The same is true of mask-wearing and social distancing, which is fundamentally against all of our social and cultural norms and obviously, objectively makes social interactions worse. Any policy based on requiring (or expecting) people to perform these actions is bound to fail, especially if no one is trained in how to do these actions safely and is not receiving the correct equipment. The policy is particularly likely to fail because the people who don’t conform will spread their virus in ways that people who are conforming cannot see and prevent (such as touching surfaces that mask-wearers touch).

A good public health strategy needs to take into account what people are willing and able to do, and not assume everyone will act correctly and in good faith. A policy which plans to increase risk in other ways – by reopening the economy – while relying on people doing these difficult and unpleasant individual actions to offset the risk is guaranteed to fail. And as we see in America, and now increasingly in Japan, that is exactly what has happened.

What does this say about the future of COVID-19 policy

There is only one safe and reliable way to control this epidemic: lockdown your cities until there are 0 cases, then reopen slowly and carefully with immediate and aggressive lockdowns as soon as outbreaks happen. Coupled with rigorous control of national (and sometimes sub-national) borders, this will ensure that states can get to 0 cases and stay there with minimal future risk. If every country proceeds on this basis we can slowly reconnect countries that have eliminated the virus, and reopen the global economy. But so long as governments think they can reopen the economy provided that individual citizens take reasonable actions to protect themselves in the presence of remnant cases, the epidemic will restart and countries will continually bounce between lockdown and tragic, fatal reopening. This does not mean that you should not wear a mask – as we saw above, they probably have some mild protective effect. But you should not – and your government should not expect you to – use it as the only defense against this virus just so that economies can reopen. In the face of a virus this transmissible and deadly, there is no way your individual actions will make any difference. We need to work together through collective action to destroy this thing. Until a vaccine comes along, our individual effort is meaningless: we rely on policy and social action to end this scourge. Whenever a government asks you to wear a mask to protect yourself and your friends, that government is asking you to take the blame for its failures. Don’t let it happen. Demand real collective action to end this epidemic and restart our lives.