COVID19: Heroes Wear Masks

by Raywat Deonandan, PhD
Epidemiologist & Associate Professor
University of Ottawa
(I add my credentials to these COVID-19 blog posts in case they get shared. I want readers to know that my opinion is supposedly an educated and informed one)


A lovely thing manifested from the awfulness of the COVID-19 pandemic. During the horrors of daily death in Italy and Spain, residents confined to their homes would take to their balconies every night to applaud their heroes, the health care workers. The practice caught on around the world. In many Canadian cities, each night at dusk, grateful citizens bang pots and raise a toast to all essential workers. It’s a reminder that in the early phase of this emergency, it was doctors and nurses who held the front line, putting their bodies and families at risk to keep the rest of us safe.

Close behind them metaphorically, but physically crouched safely behind computers and spreadsheets, were my brethren, the epidemiologists and number nerds who sleeplessly pored over case data to project the course of the pandemic and offer policy guidance to government actors. The latter were struck with the ultimate responsibility of deciding the health and economic fates of entire nations; a thankless task indeed. All that was required for the rest of society was to stay home and stay away from each other: express easy heroism by watching Netflix and learning to bake.

As the wave has subsided (but not extinguished), and as the shuttered doors of the economy now begin to creak open once more, the responsibility for managing this pandemic has shifted. No more is it the domain of the masked and gowned heroes in the hospitals, or even the arcane ken of infectious disease modellers, whose multicoloured curves were the compulsion for our new indoor lives. Now, and from this point forward, it is put upon the common citizen to take responsibility for mitigating the next wave of this disease.

Everyone must now maintain physical distancing, limit socialization to a bubble of acquaintances, and wear a mask when engaging in any public indoor activity. The doctors and scientists have a much smaller role to play. This puts us in interesting waters. Clinicians follow textbooks and protocols. Epidemiologists follow trends and formulae. But there really isn’t a playbook for compelling public participation in a large scale public health adventure.

North Americans have had a mixed history of compliance with public health recommendations that relied upon voluntary action for the greater good. Smoking rates did not diminish in most communities until the force of law was used to discourage smoking in indoor public spaces and to prevent children from taking up the habit in the first place. Seat belts have been available in cars since the 1920s, but their use did not exceed 50% in Canada until it was made mandatory in the 1970s. And even now, expensive tickets are still meted out daily for failure to buckle-up. Similarly, speed traps, photo radar, and enormous fines are needed to prevent a segment of society from making highway driving exceedingly dangerous for everyone else.

Common sense ain’t so common.

The obvious lesson is that our society has a poor track record of “doing the right thing” when it comes to public health and safety expectations. Unfortunately, when it comes to the protection of the greater community, it must then fall upon government to make compliance obligatory by using the blunt force of the law. The state must flex its ugly authoritarian side, and liberal democracy trembles for it. But sadly that is the nature of a public health emergency that cannot tolerate more than a handful of people not accepting the seriousness of the stakes. Rights will be curtailed when citizens don’t embrace their responsibilities.

We’re talking about mask usage, of course. Masks are now mandatory in many parts on Ontario as cities have enacted bylaws to help prevent the spread of COVID-19. With this requirement has predictably come the contrarian response, arguing that such requirements are oversteps into our personal lives and freedoms.

From the perspective of a public health communicator, the challenge of reaching mask-resistors is threefold. First, many do not accept the underlying science behind mask use, nor indeed the entirety of the COVID-19 narrative. Much of this attitude springs from ideology, and one cannot challenge ideology with evidence, especially when loud and unceasing conspiratorial noise is so easy to find on the internet. Such ideology is a deeply-entrenched sentiment that often requires profound introspection or trauma to dislodge. It is this intractable group that is best served by legal compulsion, as more subtle public health encouragement will fail.

Second, much of the rationale behind compulsory mask use is based upon the need to protect others. “My mask protects you and your mask protects me,” goes the mantra, as most non-N95 masks offer the wearer little personal protection, but rather help reduce overall community transmission. This is distinct from other public health investments. A seat belt protects the wearer, after all, and not the person in the other car. Efforts to convince men to wear condoms to protect their partners from STIs, or to convince smokers to quit in order to save others from second-hand exposure, have not been particularly successful. Public health, unfortunately, is mostly an appeal to selfishness. And those resisting mask-wearing are mostly operating from a selfish place and need to be met there.

To help assuage most people’s reflexive selfishness, we must draw the connection between social responsibility and personal gain. If enough people wear masks, the community transmission rate declines and further outbreaks become less likely. This translates to a greater likelihood of businesses staying open. Everyone wants to be able to shop at the mall, eat at a restaurant, or drink a beer on a patio.

Last is the great ongoing communication challenge of this disease: risk perception. The probability of an individual in Ontario getting COVID-19 is low (especially now that the incidence rate has dropped). And for those who do get it, the probability of living through the experience is very high. This reality has fueled much of the anger surrounding the “lockdown”, with many unable to understand why their movements and freedoms are being restricted when they are at minimal risk of anything bad happening to them.

But this has never been about individual risk. If a given COVID patient has a 0.4% chance of dying, that’s a vanishingly small risk. But when scaled up to a population of millions, that translates to tens or hundreds of thousands of deaths, much human suffering, and a stressed health care system.

This is the crux of the issue: the threat is not to the individual, but to the community. But we have a culture, media, and tradition that is very much set in an individualistic mindset. The threat of an infected person giving the disease to another person who might give it to a third person who then dies is so abstract and untenable that it fails to sufficiently compel individual action.

That, then, is the mountain we must climb: to convince individuals to make daily changes to their lifestyle in order to enact an unseen theoretical effect on people they will never meet. Frankly, what we have before us is a challenge of imagination.

But this is what must happen. Everyday citizens must rise to this challenge and be worthy of receiving the dusk applause that was once reserved for health care workers. Be heroic. Heroes wear masks.