At the six-month anniversary of the largest Covid-19-related national lockdown, the pandemic theatre is winding down — the bizarre night curfews, the state-sanctioned distribution of Ukalo, the colour coding of India into red, yellow and green patches apropos of nothing, the Covid-busting apps that were supposed to deliver the nation, and even the blind faith in the cure-all hydroxychloroquine, are all losing steam. But the pandemic is not, and continues to ruin lives and livelihoods. While quarantining, isolation and treatment are critical for those exposed or infected, at this late stage when contagion has spread across the nation, there seems to be diminishing attention to the two vital yet simple interventions that can still help mitigate spread: masking and handwashing.
Last month, a network of medical student volunteers across the country stepped out of their homes to observe how a few hundred fellow citizens masked while shopping at the local market. They found wide variation in whether or not customers and vendors were masked properly by visiting 30 local markets across 19 cities on nine different occasions. Of nearly 4,500 people observed, nearly one in four were not wearing masks, and of those who were, nearly one-third to one-half did not wear them properly. In effect, nearly 2,528 of the 4,548 people (more than half) were not effectively masked.
This should worry every single one of us. Masking is one of the last arrows left in our quiver, if and until an efficacious vaccine arrives.
A few months into the pandemic, it became apparent that we were not dealing with a virus that spread as easily as measles or Ebola. Covid-19 is mostly spread by an infected person, whether symptomatic or asymptomatic, when they speak, cough, sneeze or perhaps even when they eat, in company. We also know that inoculum (dose) plays a role: how many viral particles an infected person sprays into the air matters, and even more importantly, so does how many of those particles we inhale. Of course, age and underlying health will greatly influence the ability to fight the virus: the majority of Indians are in their 20s and while they have not died from infection despite millions having contracted it, they continue to pass it on to others who may be more susceptible. Transmission through contact with contaminated surfaces seems to be less of a concern than originally estimated, though abandoning caution is not warranted.
A recent article in the New England Journal of Medicine went so far as to suggest that masking, by reducing inoculum, may in fact be inadvertently resulting in asymptomatic infections, and subsequently, immunity. We in India should know this. After all, the story of Shitaladevi is not a myth. For centuries, “tika” was practiced in India, where a smear of fluid from the pustules (boils) of patients with smallpox was applied to the pricked skin of a healthy person under the watchful eye of the “cooling goddess”, with the effect — then unbeknownst to them — of triggering a milder form of infection, and, consequently, immunity! Dose-modified exposure explains why unprotected family members, nurses, doctors, or co-workers are most likely to be get infected and become sick. After the initial toll on healthcare providers in New York City, other cities in the United States that had the time to prepare for the surge, like nearby Boston, did not experience the same mortality in healthcare providers. They had time to ensure not only that clinicians were adequately protected at work, but also that the public were masking at all times.
Dr Satchit Balsari is assistant professor of emergency medicine, and of global health and population at Harvard’s medical and public health schools. His interdisciplinary research is at the intersection of mobile technology, disaster response, and population health. He currently directs the India Digital Health Net at Harvard’s Mittal Institute.
How to mask?
There are literally hundreds of videos out there about what kinds of masks to use. This is not rocket science: the first goal is to prevent breathing in the virus, by eliminating direct inhalation and minimising any chance that we deposit a large quantity to our face by touching it with our virus-coated hands! The second, and perhaps even more important, is to prevent infected individuals from spreading infection, while breathing out.
Some covering is better than no covering, a surgical mask that fits properly with no gaps at the side is even better, and an N95 respirator is perhaps the best, but an overkill in most cases and not feasible to wear all the time. The N95 is a must for all up-close nurse-patient or doctor-patient exposures, and preferably with accompanying eye or facial protection, like goggles or a shield. Frequently resting the mask on the chin is a bad idea, as you may breathe in what your mask had only just effectively filtered out. It is standard practice among my peers to instead remove the mask entirely and hang it on a hook, or place it outside-face down, when it must be removed.
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So, why aren’t we masking?
Folks are fatigued especially when nothing seems to have worked. Scientists have been warning about the danger of pseudo-science: while the pandemic called for urgent interventions, there was no place — none — for just any intervention. The “something is better than nothing” attitude that may be an okay-ish life philosophy but a terrible public health strategy resulted in a range of prediction models and apps based on incomplete testing-data and poor understanding of transmission dynamics, draconian isolation strategies that instilled fear, and hospital-building when there have never been enough doctors to even staff the facilities we have. When intervention after intervention fails to deliver, public health authorities risk eroding one of the most critical elements of effective response — trust.
Blaming the state, however, hardly absolves us from individual responsibility. How many middle class Indian households that have so impatiently awaited the return of domestic helpers have bothered to provide them an extra box of masks or sanitisers or even soap for their families of their employees? These are all prohibitively expensive on the meagre wages that our domestic workers make, but cost a fraction of what ventilators do. It has always been convenient to blame India’s woes on its illiterate masses. But Covid-19 was not incubated in our slums or hinterland — it was brought to India on flights, and spread through our cities and then across India through colossal miscalculations by the urban elite. Leaving everyone to fend for themselves is not just cowardly but amoral.
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Wearing masks in hot and humid India is not easy. What is needed is a thoughtful aggressive mass-media campaign “in mission mode” to demonstrate how to make simple face coverings at home, and reinforce why they are still important, despite the oppressive realities of life in a densely populated and poor nation — the commute in packed buses and trains, crowded living conditions, and working in sweltering hot spaces with poor ventilation. Billionsocialmasks.org which brings together women’s empowerment groups and scientists is one of many such examples.
Grand gestures are not entirely unjustified — sometimes the theatrics are needed to galvanise the public’s attention. But having lost public trust, now asking people to simply mask up, is a communications nightmare. The greatest successes in public health however have had very humble origins. Advances in sanitation in London resulted in some of the largest gains in life expectancy in the 19th century. In the 20th century, in the cholera camps of Bangladesh, the concoction of a pinch of salt and a tea-spoon of sugar with a glass of water allowed resuscitating deathly ill cholera patients back to life at little cost, when it was impossible to provide thousands of patients intravenous fluids. Those of us from that grew up in the single-channel Doordarshan era remember television campaigns where women would go door to door advising neighbours on how to make oral rehydrating solutions at home. This simple unsung intervention continues to be a highly effective treatment for millions around the world, ensuring that the right concentration of ingested glucose and sodium triggers specific cells in the intestine to absorb water, compensating for the life-threatening water losses cause by the bacterium, Vibrio cholerae.
The parade of leaders that goaded folks to stay at home, give up their jobs, and download apps, must now resurface, acknowledge the state we are in — widespread community transmission — and explain why the only effective way forward, until the vaccine arrives, is to continue social distancing (for the few that can afford the luxury), and masking and handwashing for everyone. Policing is not the only way to ensure compliance; re-energising our largely pliant population to make masking the norm, and unmasking socially unacceptable, would be wise. Widespread distribution of soap and effective masks will be exponentially more beneficial than distributing potions. How incredibly powerful would it be if the nation’s highest offices inspired people to collective action — this time, in the service of science.
Acknowledgements: I thank the medical student volunteers from the Rotaract Club of the Caduceus for their contribution to the article.
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