We Should All Be Wearing Cloth Masks, And Here’s Why

Posted: 18 May 2020 06:56 PM PDT

Legal Nomads began in 2008 as a travel site, and during the subsequent decade it morphed into a travel and food site as I lived around the world. Then, it shifted into a place to share the reckoning and grief that accompanied an abrupt life change. These days, it remains a place to share my thoughts on what’s going on around us, even if now we are all not able to explore the outside world. For now I wanted to talk about masks.

Specifically cloth masks.

Specifically the fact that many people are resisting wearing them.

I’ve been banging on about masks since I wrote my previous COVID-19 piece in mid-March, including via Instagram. But the subject is so important that I wanted to address masks in a standalone post.

I believe in individual liberty. But we should not use the concept of liberty as a pretext for acting selfishly toward society as a whole. Entitlement to freedom in a moral sense evaporates when the exercise of that freedom becomes harmful to others. By now, there is overwhelming scientific evidence that wearing masks in public dramatically lowers the risk of you spreading COVID-19 to others. And as I reiterate below, given that a large percentage of COVID-19 cases are asymptomatic, you may be infecting others without even knowing it.

Let’s get to it.

Cloth masks help you protect other people

The guidance regarding masks has been convoluted at best, with countries around the world taking very different positions to whether or not they ought to be worn.

But there are two discussions here: whether a mask protects YOU, and whether a mask protects others FROM YOU. You may have seen articles talking about ingress (will a mask protect you from the droplets?) and egress (will you wearing a mask protect others?).

Unfortunately, most of the focus has been on ingress only, and whether one can be protected by wearing a mask. For some time, the CDC and WHO focused on this issue and how only medical staff should be wearing N95s and surgical masks. Rightfully, those medical providers need to be properly outfitted with personal protective equipment (PPE), and we’ve all seen how there was a mad scramble for PPE in many jurisdictions. Protecting the mask-wearer is not easy. It requires strict protocol, medical-grade respirator masks, a proper fit, and contamination concerns. But it’s necessary to keep our doctors and nurses safe.

In contrast, masks that are worn to prevent COVID-19 transmission to others are a lot more simple to handle. A cloth mask can be used, and it lowers the viral load circulating at one time, thereby reducing the exponential spread of the virus throughout society. It makes a big difference. As The Atlantic notes, “It's like stopping gushing water from a hose right at the source, by turning off the faucet, compared with the difficulty of trying to catch all the drops of water after we've pointed the hose up and they've flown everywhere.”

There was lots of focus on PPE in the press (and studies), but less discussion about the benefit to everyone when the majority of society puts on a simple cloth mask. We wasted valuable time that could have prevented people from dying. In countries where there was a swift about-face to require wearing of cloth masks, the transmission rates plummeted. And thankfully, more and more countries are following in their footsteps.

Using a mask can help lower the risk of your unknowing transmission of COVID-19 to others

COVID-19 can spread in different ways, and one of them is via the droplets that hurtle out of our mouths. This outburst of droplets happens when cough or sneeze, but also when we speak. A single cough can release 3000 droplets. A portion of these droplets quickly evaporates to become something called droplet nuclei, which are tinier particles that are harder to protect against. They can be easily inhaled by anyone nearby.

But wearing a cloth mask has been shown to slow down that evaporation process. So much so, that in studies, a cotton mask reduced the quantity of virus particles emitted from mouths by as much as 99 percent. (2) This is because in the moist space between a person’s face and their cotton mask, it takes a lot longer for a droplet to evaporate into a droplet nuclei. The mask increases the humidity in the area, which prevents the droplets from getting tinier — meaning the fabric can still prevents them from being flung into the outer world.

Mass masking both prevents others from being infected by you, and if everyone is speaking moistly (3) into a mask, it lowers the overall burden of the virus in the area. Lowering the viral load in the area will also help protect essential workers.

People with no symptoms drive half of transmission for COVID-19

Here’s where COVID-19 throws a giant wrench into the common saying that you should only wear a mask if you’re sick: many people are transmitting this virus despite having no clue they are carriers. (4) This “oblivious transmission” issue is a huge driver of outbreaks for this pandemic. These oblivious carriers are divided into two categories: asymptomatic people, who never show symptoms, and pre-symptomatic carriers, people who are infectious but are not yet feeling any effects from carrying the virus – but will eventually develop symptoms.

As of mid-March 2020, studies were already showing that even if you're fully asymptomatic, you can still spread this virus as a vector. Further articles demonstrated that the same is true for patients who will become symptomatic but are in a pre-symptomatic state. In fact, those patients are most contagious during the time when they’re pre-symptomatic.

So if people only wear masks when they’re actually showing symptoms, that doesn’t fix the problem.

face masks can stop the spread of covid-19

From: Face Masks Against COVID-19: An Evidence Review

Wearing a mask does not mean social distancing and hand-washing are off the table

Have you seen people moving their masks around to talk? Or touching their faces and then food? Yes, me too, and it’s horrifying.

Mass masking is not a substitute for other precautions, and still requires the same amount of common sense as we needed to exercise pre-mask wearing. Social distancing and hand-washing are still critical to control the spread of COVID-19. Masks are a an accessory to other precautions.

Just because you wear a mask doesn’t mean you should go and cuddle up to someone you haven’t seen in awhile. It doesn’t mean that you should ignore the social distancing recommendations. And as the weather warms up, it certainly doesn’t mean you head out and throw caution to the wind.

It means: add this one simple thing to your existing routine, and you will help save many lives.

It’s as easy as that.

As a piece on masks in the Atlantic states,

[O]rdinary people are not helpless; in fact, we have more power than we realize. Along with keeping our distance whenever possible and maintaining good hygiene, all of us wearing just a cloth mask could help stop this pandemic in its tracks.

There is still some opposition to cloth mask wearing, so I wanted to address a few of the objections here:

“Hypoxia (deprivation of oxygen)”. No, hypoxia is not an issue with breathable cloth masks. Also, yes, it’s hard for doctors to breathe in N95s, and I empathize with their needs to wear PPE (masks and gowns and more) for long stretches since that equipment is very uncomfortable, but that’s the only way for them to be safe in treating people who come in with COVID-19 given the high viral loads they are exposed to at work. Even for those with asthma, wearing masks is recommended.

“Ok fine no hypoxia. Hypercapnia (abnormally elevated carbon dioxide (CO2) levels in the blood)”. Also a no. Arguments that wearing a mask can do this due to “rebreathing your own exhaled CO2 by wearing a mask continually" are false. Many doctors, scientists, and industrial workers have routinely worn masks for prolonged periods of time without any clear adverse effects. As this AP piece fact-checking the hypercapnia claim states, “with how common mask wearing has always been, even before COVID-19, we would know if hypercapnia was a problem with wearing masks.” In addition, since I’m advocating for wearing masks made from breathable cotton, the hypercapnia claim is even more baseless than if I were urging everyone to don an N95.

“Studies about the size of the droplets for COVID-19 show that they’re small microns, so cloth masks don’t work.” Yes, that’s the big issue with ingress: inbound droplets. But my argument for cloth masks is based on egress, outbound droplets. The studies cited below are specifically using conditions comparable to COVID-19, and are new because we didn’t focus too much on egress previously – but now we have great reason to. We are trying to prevent giving others our droplets, and that’s why cloth masks only work if we all wear them. We’re trying to make sure we don’t unknowingly contaminate others.

“But doctors need masks” Yes, that’s why we aren’t using theirs. The piece you are reading (and others, see the sources below) discuss how cloth masks work very well to stop the spread of COVID-19 if worn by the vast majority of people when out in public. We only need to look at the Czech Republic, Austria, and and other places that have mandated them to see just how well they’ve prevented spread.

“But the CDC said not to wear them if healthy” Reality is that this is a new virus and scientists and doctors are all learning as they go. Once medical professionals and epidemiologists realized the staggering percentage of cases transmitted via asymptomatic vectors, they – including the CDC – shifted from their initial guidance to now recommend the wearing of cloth masks. And those countries that switched course quickly to mandate masks are faring a lot better than those that did not.

“Masks increase the risk of infection for the wearer.”Back in March 2020, which is basically decades ago in COVID-19 time, the U.S. Surgeon General and others were recommending no wearing of masks, and opined that wearing certain types of masks increase the risk of infection for the wearer. At that point in time, the discussion was about N95s and surgical masks, and those same articles discussed ensuring adequate PPE supply for doctors, nurses, and other healthcare workers. Here we are talking about a cloth mask, which is a very different situation as purchasing or creating a DIY one does not imperil the supply of medical masks for the medical professionals who need them. And again this is a discussion about egress, not ingress. There was a 2015 study from Hanoi, Vietnam about how cloth masks worn by healthcare workers who are in close contact with sick patients for long periods of time increased those healthcare workers’ risk of respiratory infection. That is again not what we are talking about here. You and I are not healthcare workers who are going to wear our masks while attending to hospitalized patients; our mask wearing as stated above is about not infecting others.

“But freedom!” I know some places have been convinced that freedom is at stake, but if we look around the world the countries that did abide by lockdown and mask orders are those that are doing the best. They are now opening up. Their people are now able to move around safely. The countries that did not impose such measures, or implemented them in a weaker fashion, are where the virus is still spreading rapidly. Either way, it’s hard to view a temporary requirement to wear a mask when outside the home as a meaningful restriction of one’s rights – particularly when viewed in the context of the substantial benefits of such a requirement.

After living in Asia for many years, where it’s considered customary and reasonable to protect others from becoming infected by you when you’re ill, I wore masks when unwell with contagious diseases. Excluding specific and limited exemptions, for example people who are hearing-impaired* or have a disability that makes it hard for them to wear or remove a face covering, there are only self-focused reasons not to wear one during a pandemic. And this is not a time to be self-focused.

The freedom to breathe on others in ways that may kill them is just not a reasonable thing to desire.

I wear a cloth masks to protect others, but that can only have a meaningful impact in reducing the society-wide harms from COVID-19 if others do the same.

-Jodi

* There are ClearMasks for the hearing-impaired community, but to my knowledge they are not widely available nor widely accessible.

Where to Buy Cloth Masks

I got mine from my friends Bethany and Randy, who are sewing them and donating one for every one sold. You can get yours here. They are also making them with pockets so that filters can be added if desired. Be sure to specify in the notes section if you have a particularly small or large face.

Options for kids cloth masks can be purchased here, to be put on with parental supervision.

Another option is to make them at home, if you’re able to. Patterns abound.

Pleated surgical-style mask out of fabric, here.
Craft Passion’s mask with covering for the nose and elastics around the sides here, in 4 different sizes including for kids ages 2 and up.
Masks for the hearing-impaired here.

Cloth masks should fit snugly but comfortably, and tied with elastics or adjustable fabric. They ought to be two layers at least of breathable fabric, and be able to be washed (see below) without damaging the materials.

Good Housekeeping notes that “tightly woven, 100% cotton is the best fabric to use, which means you can turn a bandana, or fabric from pillowcases, curtains, or woven shirts into a face mask or covering. Be sure to avoid knit fabrics, like jersey T-shirts, because they create holes when stretched. To make the mask even more protective, use a nonwoven interface, coffee filter, or HVAC filter (as long as they don’t contain fibreglass) inside the mask to help block particles.”

Proper Care for Cloth Face Masks

Yes, these masks need to be washed and cared for in order for them to keep working. Guidance from the CDC on doing so here. I wash mine on a gentle cycle, or hand wash them with hot, soapy water, after each use.

As with anything you may touch that is contaminated it is important to wash your hands if you touch your face with your mask on, so that you don’t contaminate the next thing you touch. Also thoroughly wash your hands for those 20-seconds you now know well after you remove your mask.

Sources

(1) On droplet size

The airborne lifetime of small speech droplets and their potential importance in SARS-CoV-2 transmission

(2) On how cotton masks can help curb the spread of COVID-19

Masks help stop the spread of coronavirus – the science is simple and I'm one of 100 experts urging governors to require public mask-wearing. (The comments from others when I shared this piece is what inspired me to write this article)
Visualizing Speech-Generated Oral Fluid Droplets with Laser Light Scattering
Face Masks Against COVID-19: An Evidence Review
Universal Masking is Urgent in the COVID-19 Pandemic
CDC’s recommendations to now wear cloth masks
Wearing face masks in the community during the COVID-19 pandemic: altruism and solidarity

(3) The “speaking moistly” is a reference to Canada’s PM Justin Trudeau, who used the phrase at a press briefing — and seemed to immediately regret it.

Someone creative made it into an autotune song, and it is glorious: