Masks vs. shutdowns is a false dichotomy
When one follows the public discussion about the response to the Covid-19 pandemic, one increasingly gets the impression that there are only two alternatives: shutdowns or masks. Either everyone is made to wear the latter, the logic goes, or governments will have no choice but freezing the social life.
Although these measures appear very different at first sight, they have certain important commonalities. They are both sweeping, superficially plausible and easy to impose on the population as a whole by government decree. They create the impression that something really is being done. At the same time, neither of them is actually based on sound logic or evidence.
Prior to the Covid-19 pandemic, lockdowns had almost never been seriously considered as a policy option. But even after their worldwide implementation, it is still at best dubious that they are actually worth their astronomical cost. Compared to most other European countries, Sweden only imposed very light legal restrictions on its residents, yet, its Covid-19 deaths per million are below those of many developed countries with lockdowns, let alone those in the worst-hit US states of New York, New Jersey and Massachusetts. The excess deaths in Sweden are below the European average, according to the research by Michael Levitt. Moreover, the vast majority of Swedish deaths have been among the long-term care residents, instead of the general population at which lockdowns are aimed.
It is true that Sweden has had a much higher mortality than the other Nordic countries, however, there is compelling evidence that Sweden had a much larger initial epidemic size. The Nordic country with the second highest Covid-19 mortality is Denmark. The capital regions in both Sweden and Denmark have been the countries’ epidemic epicentres. Just two weeks into the epidemic, adjusted by population size, the Stockholm region had around 2.19 times more hospitalizations than the Copenhagen region. This was way before Danish government measures could make any difference. See my Twitter thread here for details.
There is also a plausible explanation for why Sweden was more heavily hit that I did not know about when I wrote that thread. The winter school break in the Stockholm region happened to be on February 24–28. A lot of Stockholm families went to the Italian and Austrian Alps at the same time, right when the epidemic was raging uncontrolled there.
Outside of Europe, Peru has had one of the strictest lockdowns in the world imposed early. It even involved curfews starting in the afternoon. Yet, Brazil with much more patchy restrictions has fewer deaths per million, according to Worldometers. East Asian countries with mild restrictions such as South Korea, Japan and Taiwan have managed to avoid significant mortality altogether. Finally, many places where lockdowns were imposed in spring with low preceding spread (California, Israel, Florida, Australia) are now facing resurgent outbreaks, which suggests that they only succeeded in delaying the spread at an enormous cost.
Just like lockdowns, masking has little to show for it in terms of evidence. Masks, especially cloth masks, have not been demonstrated to significantly reduce respiratory disease transmission outside laboratory experiments, and cloth masks may actually contribute to respiratory disease spread. A large randomized trial conducted in 2011 in Vietnam compared the incidence of influenza-like illness among the medical workers who wore medical masks, who used cloth masks and who used no face coverings at all. The cloth mask group had much higher incidence of illness than even the no-mask group.
Mask mandates are certainly much less damaging than shutdowns. However, the problem with it is that it distracts from the genuinely evidence-based approaches to limiting Covid-19’s tally of victims. The authorities in most countries clearly seem to consider masks a simple panacea that they almost certainly are not. And once the mask mandate fails, they will face calls for more shutdowns.
Fortunately, there are better ways of dealing with Covid-19. The fact that it seems to overwhelmingly spread in poorly ventilated indoor spaces, sometimes rapidly among many people, suggests that the spread may be mostly airborne. In fact, recently, an open letter by 230 scientists made the WHO recognize the importance of this route of transmission.
But this should not be a reason for panic or masking mandates, as most masks cannot filter aerosols effectively. Instead, boosting indoor ventilation could be a big step forward. And there is no need to artificially make the indoors like the outdoors. A recent experiment by Dutch researchers has shown that simply opening the door and a small window of a room dramatically reduces the time needed for half of the respiratory aerosols to disappear. A study at the college campus at the University of Maryland demonstrated that the incidence of acute respiratory diseases of all kinds was reduced by four times in a better ventilated residence hall compared to the one with inferior ventilation.
Furthermore, almost everywhere in the developed world, at least half of the reported Covid-19 deaths have been among the long-term care residents. Limiting spread there through frequent targeted testing and other approaches seems to be much more important than trying to curb all spread in the society at large. Research conducted in the US state of Georgia discovered that the nursing homes that screened their staff and residents preventively rather than in response to newly-discovered infections had very low levels of transmission.
Finally, a recent study conducted in the Paris region strongly suggests that overcrowded housing conditions have been the key driver of Covid-19 mortality differences among municipalities there. Previously, the Wall Street Journal has published a well-researched in-depth piece with further evidence on this phenomenon. Focusing on advising and helping people at high risk of severe disease to avoid cohabiting with others could further reduce the Covid-19 damage. Teaching people to ventilate their apartments better could well help, too.
It is time to ditch panic and sweeping society-wide measures in the fight with Covid-19 that do not have sound evidence behind them. Instead, targeted and context-dependent approaches such as boosting indoor ventilation in indoor spaces where it is needed and tackling the spread among high-risk groups hold a lot more promise.