Thursday, August 13, 2020

At the heart of dismal U.S. coronavirus response, a fraught relationship with masks

Jul 29. 2020
Matt Serenius helps his daughter Sloane Serenius, 2, put on her mask in Washington last week. MUST CREDIT: Photo by Amanda Andrade-Rhoades for The Washington Post.
Matt Serenius helps his daughter Sloane Serenius, 2, put on her mask in Washington last week. MUST CREDIT: Photo by Amanda Andrade-Rhoades for The Washington Post.
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By The Washington Post · Griff Witte, Ariana Eunjung Cha, Josh Dawsey · NATIONAL, HEALTH 

Mike DeWine had blazed a trail in March with his forceful response to the coronavirus pandemic, rapidly shutting down his state to protect it from the worst ravages of disease.

A month later, Ohio's governor made what seemed, by comparison, a modest proposal: If businesses wanted to reopen, customers and employees would have to wear masks.

A man wears a mask around his wrist while walking in Washington last week. He said he didn't like wearing his mask because he recently had open heart surgery and is still experiencing breathing problems. MUST CREDIT: Photo by Amanda Andrade-Rhoades for The Washington Post.

The backlash came instantly. An avalanche of abuse on social media. Calls from anguished citizens. Angry recriminations and threats. 

The next day, a chastened DeWine backed down. Asking people to wear a mask "is offensive to some of our fellow Ohioans," the Republican declared somberly. "And I understand that."

It would be three months - plus tens of thousands of cases and thousands of deaths - before the governor would try again.

The mask is the simplest and among the most effective weapons against the coronavirus in the public health arsenal. Yet from the start, America's relationship with face coverings has been deeply fraught.

Faulty guidance from health authorities, a cultural aversion to masks and a deeply polarized politics have all contributed. So has a president who resisted role modeling the benefits of face coverings, and who belittled those who did.

The result, experts say, is a country that squandered one of its best opportunities to beat back the coronavirus pandemic this spring and summer. In the process, the United States fell far behind other nations that skipped the fuss over masks, costing lives and jeopardizing the recovery heading into the fall.

"Some countries took out their masks as soon as this happened," said Monica Gandhi, an infectious-disease specialist from the University of California, San Francisco, "and their rates of death are very low."

In a coronavirus response that has been full of missteps and unforced errors, delayed acceptance of universal masking, Gandhi said, may be the single biggest mistake the United States has made. 

In interviews, elected leaders, health specialists and mask advocates say it did not have to be that way - and very nearly wasn't. 

The country hit a tipping point on widespread mask use only this month, with a majority of states and the nation's largest retailers all mandating them. But the science has long been pointing toward the efficacy of masks - even if the guidance from health authorities wasn't. 

In February - as the virus silently spread in communities from coast to coast - both the World Health Organization and the Centers for Disease Control and Prevention recommended against face coverings for healthy members of the general public. They urged that masks be preserved for front-line health-care workers, especially amid global shortages of personal protective equipment. It was a line repeated by top officials in the Trump administration.

CDC Director Robert Redfield was asked in February whether healthy people should wear masks. His answer to Congress was unambiguous: "No." 

Anthony Fauci, the nation's top infectious-disease expert, repeatedly told Americans "there is no reason" for anyone in the United States to wear a mask. U.S. Surgeon General Jerome Adams tweeted on Feb. 29: "Seriously people- STOP BUYING MASKS!"

The health officials had made their recommendations based on the flawed assumption that the bulk of transmission was taking place from people with obvious signs of illness. The thinking was that if people with fevers, coughs and other symptoms were to isolate, case counts would remain under control. 

But it wasn't long before CDC contact tracers began to find evidence of "silent" spreaders. One report in late March, from a skilled nursing facility in the Seattle area, found 13 asymptomatic or pre-symptomatic patients among 23 residents who tested positive.

Many experts backed the anti-mask guidance, arguing they weren't sure face coverings would make a significant difference. They were worried masks could make people less disciplined about social distancing.

But some, including George Gao, the director-general of the Chinese Center for Disease Control and Prevention, warned that the United States was making a "big mistake" by not mandating masks. 

Zeynep Tufekci, an information science professor at the University of North Carolina at Chapel Hill, examined the emerging evidence and knew that hand-washing and isolating the obviously sick wouldn't be enough. If people were spreading the virus before they had any symptoms, "that's huge. It's a whole different ballgame." 

Going against both the CDC and the WHO felt like heresy at a time when few mainstream scientists were. But she decided she had no choice. The case that masks could slow asymptomatic spread was compelling. The arguments against - particularly the idea that people might hoard medical-grade masks, when cloth ones could easily be made at home - would only feed resentment.

"If you're paternalistic and you don't treat the public as a partner, what you end up with is mistrust and polarization," said Tufekci, who laid out her views in a March 17 New York Times op-ed. "That's not how you do public health."

Across the country, data scientist Jeremy Howard was reaching a similarly against-the-grain conclusion on masks. A specialist in artificial intelligence at the University of San Francisco, he had no background in public health. But he knew how to interpret numbers.

"I had never personally worn a mask in my life. I thought they were kind of weird," he said. "But I had vaguely heard they could maybe help a little bit." 

When he examined the data - particularly from Asia, where masks had become commonplace during the SARS outbreak and were then put to work in the fight against the novel coronavirus - it was overwhelming. In Europe, too, the evidence was persuasive: Masks had become widespread within days in the Czech Republic, thanks to a campaign among cultural influencers. Transmission rates soon fell.

"I was just stunned," Howard said. "It seemed pretty likely that this was the most effective public health tool that we had."

Howard put his argument for members of the public to wear do-it-yourself or other store-bought cloth masks into a March 28 piece for The Washington Post. Senators were calling the next day, asking for private briefings. One of them, Sen. Patrick Toomey, R-Pa., was so impressed he vowed to make the case to the president. 

The White House was receptive, but only to a point.

Inside the administration, there had already been weeks of debate on masks at the coronavirus task force level without a decision on what to recommend to the public. 

In the last week of March - as the official case count was approaching 100,000 - the CDC presented what was then considered a radical proposal to the White House, recommending routine masking by the public. Senior administration officials, particularly members of the vice president's office on the coronavirus task force, pushed back, arguing it was unnecessary. 

The new guidance was somewhat of a compromise. It encouraged - but did not require - people to cover their faces in "public settings where other social distancing measures are difficult to maintain (e.g., grocery stores and pharmacies) especially in areas of significant community-based transmission." 

On April 3, President Donald Trump stood at the White House podium and issued the recommendation. "It may be good" advice, he offered. But he immediately undercut the guidance by announcing he would not be wearing a mask himself. 

"Somehow sitting in the Oval Office, behind that beautiful Resolute Desk" as he met with "presidents, prime ministers, dictators, kings, queens," Trump said, "I don't know, somehow I don't see it for myself."

Initially, some Trump aides said they did not like the idea of him wearing a mask publicly because they believed it would be bad politically and make the president look weak. They thought it might lead others to panic or think the pandemic was worse than it was. There were also fears among some in the president's circle that his supporters would rebel against anything that smacked of a government directive.

Among some of Trump's most ardent fans, anti-mask insurrections were already brewing. In dark corners of the internet, mask conspiracy theories took shape. On the steps of state capitol buildings, activists shouted their objections to a masked attack on "liberty."

Some of the president's advisers, including chief of staff Mark Meadows, expressed repeated skepticism of masks and whether they made a difference, campaign and White House officials said. Trump campaign masks were produced and presented to the president but never sold. Some aides were fearful of selling merchandise he did not wear and appearing to profit off a pandemic, officials said. 

"The President's position has been consistent on this," White House spokeswoman Sarah Matthews said in a statement. "In late March, before there was even a recommended but not required guidance given by the CDC on mask-wearing, he supported facial coverings."

With little hope for progress at the White House, Howard had begun to make his data-based case for masks to the governors, focusing especially on Republicans who had shown a willingness to embrace a scientific approach to attacking the coronavirus. DeWine was at the top of his list. 

The 73-year-old Ohioan had won plaudits from public health experts for the speed with which he shut down gatherings, businesses and schools in March when the coronavirus began to spread in the state. Cases stayed low, even as the economic damage rippled.

As pressure intensified on DeWine to reopen the state in late April, the governor seized on a mask requirement in stores and other businesses as a way to do so safely. 

Masks would not be "forever," the governor announced April 27, "but if we want to get back to work, we have to protect our employees." 

Within hours, as protests over the governor's assault on "freedom" poured in, DeWine knew it had been a mistake that would need to be reversed. 

"After 40 years of representing Ohioans in many different jobs, I've got a pretty good ability to gauge these things," he said in an interview. "And with the pushback we got, my instinct was that this was too far." 

Unlike closing schools - which could happen with the stroke of a pen - requiring masks would involve getting "millions of Ohioans making individual decisions dozens of times a day." 

And unlike in Asia - where DeWine had traveled pre-pandemic and seen the widespread use of face coverings to ward off disease - there was no culture of mask-wearing for public health benefits in the United States. 

The president's unwillingness to set an example by wearing a mask didn't help. 

"I would have liked to have seen the president do that," DeWine said.

Also unhelpful, the governor said, was guidance from some public health authorities that continued to be contradictory, even as the science behind masks became increasingly clear.

Studies suggesting masks could be effective in curbing the risk of transmission continued to accumulate. But the WHO - which has been criticized throughout the pandemic for being slow to respond to emerging data - took until June 5 to issue a mask recommendation for the general public. Even then, it was tepid and full of asterisks, with the global health body insisting the change was consistent with its original guidance.

U.S. officials have been more forthright in acknowledging their advice has shifted, arguing it was in response to shifting data. 

"If you acted on the best information you had at the time and then later you get new evidence that points in a different direction, does that mean what you did three months ago was wrong? Well, existentially, yes it was. But it was based on the evidence we had at the time," Fauci said in an interview Friday.

Once policy did shift, Fauci said, medical officials were united in getting behind the new recommendation. But other senior administration officials weren't on board.

"That was a problem," he said. 

Trump was foremost among those who weren't interested in promoting masks.

When, in late May, he toured a Ford plant in Michigan where masks were required, he refused to put one on in front of the cameras. "I didn't want to give the press the pleasure of seeing it," he said. 

Over Memorial Day weekend, he retweeted a mocking criticism of his election opponent, former vice president Joe Biden, for wearing a mask.

Videos began going viral as Americans squared off on what to do about customers in stores who refused to mask up. Social media groups devoted to casting doubt on their efficacy proliferated. Face coverings had become debate points in the U.S. presidential campaign and potent symbols in the culture war.

Public health specialists could only shake their heads.

The debate radiated through big cities and small ones as the coronavirus began a resurgence in June, with many areas that had dodged the first round of infection getting hammered this time. 

Joplin had no active cases at the start of June. Weeks later, the city of 50,000 in southwest Missouri had one of the nation's fastest rising infection rates.

For five hours in late June, the city council debated whether to mandate masks, only to defeat the motion by a single vote. 

Two weeks later, with hospitals hitting their capacities, the council voted again. This time, the mask mandate passed 6-3.

Mayor Ryan Stanley was among those who changed his mind. He had initially thought that a mandate was unenforceable and that, in a deeply conservative, pro-Trump region, it would only encourage defiance. But when he visited local businesses the weekend after the requirement kicked in, he was astonished by what he saw. 

"We were getting 15% adoption before. I was crossing my fingers and hoping for 50 to 60%," he said. "But now it's at 90 to 95%. It's certainly doing its job."

Stanley said mask opponents had been loud - staging noisy demonstrations and dominating the debate. But they hadn't actually been that numerous.

Public opinion polls bear that out, with large majorities of the population, across both major parties, favoring mandates. 

Policies have begun to match those attitudes. A cascade of states - including Ohio - have instituted requirements in recent weeks, with DeWine identifying compliance as critical to the state's hopes of bringing down infection rates and opening schools. 

Major retailers such as Walmart have as well, making shopping trips difficult without a mask.

Evidence shows the mandates are working.

"There were seat belts in cars for decades. There were lots of public service announcements, people saying, 'Wear seat belts' " said David Keating, who worked with Howard to found the nonprofit advocacy group #Masks4All. "But it's when the law started requiring it that seat belt usage soared."

Even the president has joined in - though still somewhat tepidly. On a visit to Walter Reed National Military Medical Center earlier this month, he wore a mask in public for the first time. Last Tuesday, he tweeted a photo of himself in a mask with the explanation that "many people say that it is Patriotic to wear a face mask when you can't socially distance." 

Trump wore a mask again on Monday while touring a biotechnology plant. But as recently as last week, he was barefaced while in public at his hotel in D.C., despite local rules that require a face covering.

Political advisers and campaign officials say there has been a concerted effort around Trump - from aides to family members to advisers to lawmakers - to show that wearing a mask is the right thing to do. Aides have encouraged people to praise the president for wearing a mask, hoping that he will continue to embrace it, officials said. 

It had been clear for months - as America's coronavirus case count has climbed above 4 million and the death toll closes in on 150,000 - that masks are a public health imperative. But with grim polls showing Trump trailing in almost every key state, they have now become a political one, too.

"He was basically on an island even among his own supporters," said Brendan Buck, a longtime Republican operative who last worked for then-Speaker Paul Ryan. "It doesn't take a genius to understand that this pandemic is why he's losing so badly."

 

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