(Un) Masking the Truth

Some users of social media are claiming that a “Stanford University” or “NIH” (part of the USA's Department of Health and Human Services) study has shown that face masks are ineffective against the Covid-19 coronavirus and even harmful. There’s one problem with that claim though. It’s not really a Stanford study or a National Institutes of Health (NIH) study.

OK, there are two problems with that claim: it’s not a Stanford study, it’s not an NIH study, and, in fact, it’s not even really a study. All right, there are three problems with that claim: it’s not a Stanford study, it’s not an NIH study, it’s not really a study, and oh, it didn’t really show that face masks are ineffective against the Covid-19 coronavirus. Check that, there are four problems with that claim: it’s not a Stanford study, it’s not an NIH study, it’s not really a study, it didn’t really show that face masks are ineffective against the Covid-19 coronavirus, and by the way it didn’t really show that face masks are even harmful.

Umm, let’s start again.

Recently, there have been posts on social media, claiming that a “Stanford study”, “Stanford mask”, or a “Stanford face mask study” showed that face masks are ineffective against the Covid-19 coronavirus and may have “devastating health consequences”, and that the same “study” is from the NIH or was supported by the NIH.

But, and it's a big BUT, the sole author of the publication is someone named Baruch Vainshelboim, PhD who is not actually “from Stanford,” when it comes to properly designating from where the study came. It looks like the publication has him listed  as being affiliated with the Cardiology Division at the Veterans Affairs Palo Alto Health Care System and Stanford University. However, that appears to be like a worn out underwear band as Stanford Medicine describe him as a one -year visiting scholar, and that's very different from being a true faculty member.

Also, the publication’s only connection with the NIH is that it can be found on PubMed. PubMed is a database and search engine maintained by the NIH’s National Library of Medicine (NLM). The database includes all articles that are published in a variety of biomedical and life sciences journals.

So rather than being published by, for, in, at, through, on, over, under, or on top of the NIH, the publication entitled “Facemasks in the Covid-19 era: A health hypothesis,” was actually published in a journal called Medical Hypotheses, one of over 5,000 titles that are currently indexed in PubMed which range significantly in type, quality, and focus. Some of the journals in PubMed don’t even publish scientific studies, instead focusing more on other types of papers such as commentaries, review papers, or, in the case of Medical Hypotheses: “theoretical papers.”

Yes, this journal actually published papers “which describe theories, ideas which have a great deal of observational support and some hypotheses where experimental support is yet fragmentary.” Can you imagine being asked or told to eat something with a caveat like “support that the thing is edible and won’t hurt you is fragmentary” or telling you just before a skydive that “the quality checks for parachute have been fragmentary?”

The journal description also states that that Medical Hypotheses will “give novel, radical new ideas and speculations in medicine open-minded consideration, opening the field to radical hypotheses which would be rejected by most conventional journals.” Would you feel reassured just before an operation by the surgeon telling you that he/she is "going to try a radical hypothesis that would be rejected by most conventional medical journals?”

After all, Dictionary.com indicates that “a scientific hypothesis is made before testing is done and isn’t based on results. Instead, it is the basis for further investigation.” It also says that hypothesis refers to “a proposition assumed as a premise in an argument,” or “mere assumption or guess.”

Medical Hypotheses is the journal that has published things like “Is there an association between the use of heeled footwear and schizophrenia”, “Ejaculation as a potential treatment of nasal congestion in mature males”, and “Losing weight by defecating at night.” Before you start wearing flip-flops all the time, masturbating furiously when you’ve got a stuffy nose, and sleeping on the toilet bowl, keep in mind that such articles, commentaries, and letters in Medical Hypotheses merely advance hypotheses without necessarily providing enough scientific evidence or any for that matter. After all, how many legitimate doctors will tell you, “hmm, to help us decide what treatment to give you, let’s take a look at Medical Hypotheses?” So if you have a radical idea that would be rejected by other scientific journals and a spare $1850 to pay the journal, you may be able to publish that idea in Medical Hypotheses.

Anyway, back to Vainshelboim’s article (which is not a study) about face masks presents arguments that fly in the face of scientific evidence and does so in highly flawed manner. First, when trying to claim that face masks are not effective against the Covid-19 coronavirus, the article interestingly focuses on studies of other types of respiratory viruses instead. It fails to mention the studies from 2020 that supported the use of face masks in preventing the spread of the severe acute respiratory syndrome (SARS-CoV2). As has been repeated over and over again, Covid-19 is not the flu. The SARS-CoV2 is not like influenza and some of the other respiratory viruses that Vainshelboim mentions. It seems to be more transmissible through the air, hence the face mask requirements.

Secondly, the article makes a number of leaps that really are not justified. For example, it claims that “trapped air remaining between the mouth, nose and the facemask is rebreathed repeatedly in and out of the body, containing low O2 and high CO2 concentrations, causing hypoxemia and hypercapnia,” and then cites some book chapters without really explaining how exactly these book chapters might support this claim. Is this a bit like claiming that you are an amazing lover and then citing The Joy of Sex?

Keep in mind that wearing a standard face mask is not the same as wearing a fish bowl or solid concrete and a microwave oven around your head. Oxygen and carbon dioxide should be able to move through the face mask material, assuming that you didn’t just take a condom and stretch it over your nose and mouth.

Then the article says, “severe hypoxemia may also provoke cardiopulmonary and neurological complications and is considered an important clinical sign in cardiopulmonary medicine.” How exactly would a standard face mask, which again allows oxygen to pass through its material, even cause “severe” hypoxemia, which is very low levels of oxygen in the blood, in most healthy people? If your oxygen levels have ever gotten that low, there’s a good chance that you would have already felt lightheaded, short of breath, and like you are going to pass out before experiencing any more longer term problems. This makes the next statement in the article potentially misleading: “low oxygen content in the arterial blood can cause myocardial ischemia, serious arrhythmias, right or left ventricular dysfunction, dizziness, hypotension, syncope and pulmonary hypertension.” A person doesn’t just develop conditions like a heart attack (which is apparently myocardial ischemia) or pulmonary hypotension just from wearing a face mask. These are conditions that develop over time from other factors. For example, a person typically has underlying coronary artery disease before suffering a heart attack.  

I'm all for debate and the sharing of information, but it needs to be open, honest and accurate. In this instance, it's surely theoretically possible that someone convinced by the article to not wear face masks, catches and transmits the Covid-19 coronavirus to someone else as a result? The other person could end up suffering or even dying. And that’s not just a hypothesis, given how much the article is getting shared on social media and used an ammunition in a war against mask wearing, it’s a real concern.

Tin Foil Hats Don't Protect Against Alien Abduction Either

I read in yesterday's Times about a Canadian study which claims to show that face masks can almost halve the number of new Covid-19 cases, but with the caveat that it has not yet been peer-reviewed. So, being more than mildly cynical about the efficiency of wearing non-medical face coverings to mitigate against the transmission of microscopic organisms, I've been and found it....

For the study, the authors looked at the difference in case growth rate between Ontario’s 34 Public Health Units (PHUs) and between Canada’s ten provinces during the period when some had mask mandates in force and some did not. They allowed two weeks for mandates to have an impact on reported cases, and did additional primary research to show that the mandates did in fact coincide with a change in reported behaviour (i.e. more people reported wearing masks).

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Source: https://www.worldometers.info/coronavirus/country/canada/

The first point to be made is that the mask mandates came in during the general decline of the epidemic and the period of low prevalence in July and August when there were only around 400 cases per day nationally in Canada. This makes the data highly sensitive to the testing regime and susceptible to false positives. It is noteworthy that there was a substantial increase in testing in July, showing up as a bump in the otherwise declining cases curve. At the time Ontario was recording just 100 cases or so per day. Divided between the 34 PHUs, that’s just three each per day. At a time of very low prevalence and high levels of testing such data cannot be considered reliable.

From a big picture point of view, it is of significance that once masks were mandated everywhere in Ontario (from July 8th) and Quebec (from July 18th) by the end of August cases started climbing again and have continued to do so as autumn has drawn in. Additionally, if you look at the cases curve for each province the impact of increased testing is clear but there is no sign of any impact of masks (or other intervention), just a smooth curve. Neither of these points supports the hypothesis that masks make a difference.

The main graphs the authors present do show an average difference in case growth rate between mask mandate and non-mandate PHUs and provinces for the four weeks or so in July and early August when mask mandates were not universal. In line with the authors’ hypothesis, mask mandate PHUs and provinces had a lower overall growth rate, though this was not consistently the case. It is noteworthy that the time lag from the mandate dates to the divergence in case growth of mandate and non-mandate regions is very different on PHU level and province level – two weeks versus four weeks – again counting against a claim to causative effect.

The most obvious explanation for the divergence between the two categories (mandate and non-mandate) is that the different PHUs or provinces are on different trajectories and so when they move from one category to the other (non-mandate to mandate) this has a corresponding effect on the growth rates. There is strong evidence this is the case.

On the PHUs graph we see initially in the second week of July the few PHUs with mask mandates in place have a higher average growth rate than those without one – the opposite of the hypothesis. Then, as some of those without mandates impose mandates and switch categories in the following week, the mandate PHU average growth rate quickly declines while those remaining in the non-mandate category quickly begin to show a higher rate of growth. 

Finally, in the second week of August (when the study period comes to an end), most of the remaining PHUs impose mandates and switch categories, and the growth rate in the mandate PHUs spikes rapidly. The fact that this shift results in a spike rather than continued decline is indicative that any difference was an artefact of which PHUs happened to be in which category rather than the impact of masks. In other words, they brought their higher growth rate with them into the mandate category rather than seeing it curbed by their masks. In this regard it is significant that the remaining few PHUs with no mask mandate in the second week of August actually trend below those with mandates – again, the opposite of the hypothesis.

In the case of provinces, in addition to the problem mentioned above that the average difference takes four weeks to show up rather than two, the data is skewed by the fact that only two of the ten provinces adopt a mandate during the study period so the sample size is very small and, again, the effect could be merely a function of the different trajectories of the different provinces. As noted, there is no visible sign in the case curves of the mask mandates altering the trajectories, and most provinces have seen a large growth in cases during the autumn.

The paper includes an elaborate attempt to account for the impact of other government interventions, but as this is all modelling, based on a lot of estimates and guesses, it does not address the criticisms raised here.

The evidence that the general use of cloth masks by the general population is ineffective for preventing the spread of Covid-19 (and other similar viruses) is well established. This is why the World Health Organisation did not endorse them until June, and even then stated: ‘At the present time, the widespread use of masks by healthy people in the community setting is not yet supported by high quality or direct scientific evidence.’ . It listed 11 ‘likely disadvantages of the use of mask by healthy people in the general public’, including ‘potential increased risk of self-contamination’. It all but admitted to BBC medical correspondent Deborah Cohen on July 14th that the change of policy was due to political lobbying rather than evidence. Cohen said: 

    ‘We had been told by various sources WHO committee reviewing the evidence had not backed masks but they recommended them due to political lobbying. This point was put to WHO who did not deny.’ 

The study from Canada is the latest effort to produce evidence for something that has long been established to be false. Viruses are too small to be caught by pieces of cloth and the general public will never use masks properly or keep them clean. Airborne infection is largely a function of the viral load or concentration that has built up in a non-ventilated space, not the projection of droplets from cough and sneezes, and cloth masks are useless in preventing such a build-up of virus particles or protecting from the inhalation of them. They are also bad for health in multiple ways because they obstruct breathing clean air, are bad for social interaction, and particularly bad for social psychology. 

I've been told - repeatedly - that resistance to wearing masks (especially as they don't need to be medical grade and could in theory be fashioned out of old string vests)  indicates a susceptibility to conspiracy theories, possible David Icke related madness, selfishness or even a sign of low intelligence. However, when the evidence in favour of their use is either flimsy (no pun intended), or non-existent, they are not much more than the 2020 version of wearing tin foil hats to prevent abduction by aliens.