What is the use of a systematic mask?

While the measures taken in Belgium making it mandatory to wear a mask in many public places seem self-evident to some, many doubts remain as to their real effectiveness. At Kairos, we are in contact with doctors who have opinions that contrast with the official voice. We relay their analyses and concerns. 

The saga of the masks has kept us busy all spring and continues to do so. Tragicomic or shameful, depending on how each citizen reads it. D’inutile to obligatory in all places and circumstances, the reversal of the jacket of politicians is well known to us since the song of Jacques Dutronc. The inconsistency of the so-called experts, on the other hand, is a new phenomenon that surprises and is obviously likely to encourage the politician to vary his messages over time and destabilize the citizen, who more often than not reverts to following his own judgment or that of his next-door neighbor. Is this fickleness of the scientific world explicable? Issuing a scientific opinion on the benefit-risk of a medical intervention whether it involves a drug, a medical device ( prostheses, pace-maker, implant, …) or a preventive procedure, requires a structured approach: designation of experts, evaluation procedure and consensus opinion. Are these 3 essential elements present in the case of the wearing of a mask as an element of the fight against Covid-19?

Procedures and conflicts of interest? Move along, there’s nothing to see!

The Prime Minister formed her group of experts on April 6, called the GEES (Exit Strategy) based on a deep belief in collective intelligence. Contrary to what one might think, they are not only scientists since they also include Johnny Thijs, director of companies such as Electrabel and Pierre Wunsch, governor of the National Bank of Belgium and a long-time Reyndersian. A mixed composition cleverly elaborated to nuance the opinions of scientific experts. The Prime Minister’s website also says nothing about the process of appointing this group or the possible conflicts of interest of its members, which does not bode well in terms of transparency. One of the missions of the GEES is to  » provide analysis and recommendations ». This therefore implies a description of the evaluation procedures used as whenever this kind of work is carried out in, for example, scientific societies or the drug reimbursement commission. Here again the website of the Première is silent.

Let’s come to the masks and the successive recommendations. On January 28, Le Soir-title:  » Wearing a mask is useless and ineffective according to the Belgian health authorities « . Marc Van Ranst, future member of the ESGE, and Steven Van Gucht, government spokesman, express that  » this is useless and even potentially dangerous « . On April 5, the day before the GEES was formed, Health Minister Maggie De Block communicated that  » wearing a mask scientifically makes no sense. » Other scientists will gradually take issue with his stance. On April 24, the ESWG issues a strategic report for deconfinement. Mask wearing is strongly recommended there in the public space from the age of 12, but not yet mandatory. The scientific basis for this recommendation is not provided. At the end of April, Erika Vlieghe, who chairs the GEES, said in the Morgen that  » the mask is a layer of varnish « . Finally, on July 17, a new report recommends wearing masks even indoors when spaces gather many people for an extended time and social distancing cannot be respected. This new report tells us that this could last until after the winter, with the arrival of a vaccine.

It does not appear that there is necessarily unanimity of opinion and consensus within the GEES, which is not surprising given its membership. Is there a scientific basis for these changes in opinion? Classically, for decades, scientific recommendations have been based on what l’on called evidence-based medicine. The highest level of evidence that allows for a powerful level of recommendation is achieved by obtaining multiple studies of high methodological quality comparing option A to option B and allowing for the recommendation that a treatment or procedure is beneficial, useful, and efficient, meaning that it has a favorable cost-benefit. The lowest level of evidence is obtained on the basis of expert opinion or small noncomparative studies.

What about generalized mask wearing in Covid-19 situations and what’s the rationale for the change in the GEES position? On March 3, the Cochrane Research Group, the pope of evidence-based medicine, a non-profit association of 28,000 scientists in over 100 countries, published that  » while some actions such as hand washing or wearing gloves or a mask may perhaps reduce the spread of respiratory viruses the lʼevidence is very low. » Another systematic review published this year by Marasinghe of the University of Waterloo in Canada also concludes that there is no evidence of benefit from mandatory mask use. Since then, only a German publication using a model comparing several regions where mandatory masking has been instituted points in another direction, but again the level of evidence is insufficient.

What should we conclude from this?

1. There is no sufficiently established scientific evidence today to mandate mask use for the entire population. 

2. Recommendations issued to the public by a group of experts must be justified by strong demonstrated scientific evidence. This is not the case with respect to the GEES.

3. These recommendations must be transparent and the evidence on which they are based must be accessible to all. In their absence, the recommendations are likely to create confusion in the population, leading to rebellious behaviour linked to a strong loss of confidence. The risk of accelerated spread of the virus is not negligible. There is also a significant risk that scientists who are not part of the GEES will express divergent opinions in the media, further accentuating the public’s unease. That’s what happens today.

4. The current strategic option is totally at odds with the evolution of modern medicine: the concept of « one size fits all » is completely outdated . Different recommendations should be given to subgroups of society: health professionals, frail people, asymptomatic carriers and relatives of infected patients. 

5. Experts need to provide a clear risk-benefit analysis of routine mask use for each of these groups.

6. Opinions issued should be in consultation with neighboring countries in view of the easy access to the media of these countries by the citizens. A cacophony of recommendations also has an extremely detrimental effect on compliance. This is what lʼon observes with France in particular.

7. Finally, it is surprising that no study has been initiated at the European level on the usefulness of mask wearing in view of the lack of scientific evidence and the particularly high cost of this strategy. The strident criticism of Professor Raoult’s trials, flawed as they were, stands in stark contrast to a strategy based on the scientific vacuum with respect to mask wearing. It is far from a given that such a study would come out positive but at least we would be set. As if it were already considered that only a vaccine can save us all and that it is necessary to maintain the anxiety of the largest population in order to guarantee the massive carpet bombing vaccination, in view of the colossal investments to which the European community has largely contributed. 

Cardiologist, anonymous