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[Editor’s Note: Grant application deadline struck again; so this post might look familiar to some of you. I promise new material next week.]

Of all of the disinformation about COVID-19 that’s been spreading, for all the conspiracy theories, the confluence of COVID-19 deniers, antivaxxers, and even QAnon conspiracy theorists, for all the unproven and disproven treatments (like hydroxychloroquine, azithromycin, and the like), for all the quackery that’s been promoted, even by the President, the most depressing nonsense about the COVID-19 pandemic that’s persisted and proven incredibly resistant to disconfirming science is the myth that, not only do masks not work to slow the spread of COVID-19, but they actually make people sicker. This particular myth has been very destructive to efforts by public health officials to slow the spread of the disease, leading to the misuse and abuse of the Americans With Disabilities Act, which has been incorrectly used (and, quite frankly, grossly misused) as an excuse not to wear a mask by those who oppose mask mandates. Even worse, masks (or, more precisely, refusals to wear a mask) have become a badge, a signifier, of loyalty to a particular tribe, largely thanks to President Trump’s refusal to wear a mask, dismissal of masks as unimportant, and even mocking of people who wear masks as “weak” and “afraid”, even after he himself got sick with COVID-19, largely because of his lackadaisical approach to COVID-19 at the White House.

Masks work to slow the spread of COVID-19, primarily to prevent the wearer from spreading the virus, but also, to a lesser extent, to protect the wearers themselves from coronavirus. That’s why my attention was drawn to an article by Olga Khazan in The Atlantic on the origin of the idea that masks make you sicker. It turns out that this idea is nearly as old as the pandemic and even more resistant to evidence than you might think. Khazan begins by describing the first time she became aware of the claim, overhearing it while swimming in her local pool:

About a month ago, I was in my local pool when I overheard a middle-aged woman in the next lane whisper it to her friend, in the way you vaguely assert something that you’re pretty sure is true but don’t fully understand. “Masks don’t even do anything,” she said. “In fact, they can make you sicker. Because you’re breathing in all the … stuff … you breathe out.”

“OK Boomer,” I thought. I dismissed her as a random neighborhood conspiracist and swam my laps.

I had a hard time not being a bit surprised that a journalist who has written quite a bit about COVID-19 hadn’t heard the antimask claim that masks make you sick until a month ago. I recall seeing permutations of this particular claim as far back as April, although Khazan’s article shows that the claim goes back at least a couple of months before that.

She then continues on about how she started seeing the claim more and more on social media:

But then I started to see this false notion appear more frequently on Facebook. It wasn’t the typical argument anti-maskers use, that mask mandates infringe on people’s freedoms. It was that the masks themselves are causing illness. The horror of the idea was apparent even to me: the feds, in their hall-monitor stupidity, forcing you to do something that’s actually bad for you.

Most recently, this surfaced in the form of “copypasta”—a post copied and pasted by many people onto social media, rather than shared as a link—from a purported “OSHA Inspector.” “I have worked in a clean room for 23 years and 10 years on submarines before that,” it reads. The inspector, supposedly from the Occupational Safety and Health Administration, goes on to debunk each type of mask. N95s won’t “filter your air on the way out,” so they don’t reduce the risk of catching COVID-19 from someone who has it. Surgical masks, the post claims, are rendered useless by the moisture from your breath and the “amount of particles” on them. Cloth masks, meanwhile, trap carbon dioxide, risking the health of the wearer. “I know, facts suck,” it concludes. “They throw a wrench into the perfectly (seeming) packaged pill you are willingly swallowing.”

All of these claims are, of course, false. We now know that all forms of masks can interrupt transmission of COVID-19, with the most effective being N95 masks (which I always wear while operating or seeing patients in clinic), surgical masks being next, and cloth masks being the least effective, but still more than effective enough to be worth wearing. The evidence is both epidemiological and anecdotal, for instance, when two stylists worked at a hair salon in Missouri while infected with the coronavirus, but none of the 139 clients they saw while they had it got sick, because everyone wore a mask.

My purpose with this post is not to relitigate the evidence that masks work. They do, and the evidence only gets stronger as time goes on. Rather, it’s to look at this particular piece of misinformation or frequently, when used by ideological actors, active disinformation. Khazan describes the phenomenon:

Though the latest public posts mentioning the supposed OSHA inspector date from September, the idea that masks make you sicker has been spreading online for months now, even after various fact-checking sites debunked the claim. I emailed Facebook to ask for more information about this type of post, but the company did not respond. One instance of the OSHA post was taken down after my email. But others live on, circulating among mask-haters and affirming what they perceive to be their righteousness. The post is an especially bizarre example of the “infodemic” scientists have been battling alongside the coronavirus pandemic, in which the internet is a giant telephone game reverberating with the weirdest stuff imaginable.

Welcome to the club! If there’s one thing the COVID-19 pandemic might actually be good for, it’s that it’s opened the eyes of a lot of people oblivious to medical misinformation to just how pervasive it is and how resistant to countering with evidence and science it is. Those of us who have been combatting antivaccine misinformation and disinformation for many years could have told them, could have warned them, but I’m not sure many of them would have listened, other than the reporters who had already long been covering the antivaccine movement, a distinct minority.

Perhaps the key point of Khazan’s article that resonated with me is how the myth that masks make you sick evolved organically from the claim that masks don’t work, which had been fueled by antimaskers who latched on to statements by public health officials early in the pandemic:

These videos and articles all came months after government officials had begun encouraging—and then mandating—that people wear masks in public. But crucial to understanding the spread of this particular piece of misinformation is that, for many weeks early in the pandemic, everyday people were told not to wear masks. Back then, prominent experts claimed masks were needed for health-care workers and were borderline ineffective for the general public. Versions of this advice also suggested that masks could raise the risk of illness. On March 12, Jenny Harries, England’s deputy chief medical officer, claimed that masks could “actually trap the virus.” Therefore, she said, “for the average member of the public walking down a street, it is not a good idea.” (Harries did not respond to a request for comment.)

In particular, this Tweet by the US Surgeon General has aged…poorly:

It’s true, though, that, unfortunately, early in the pandemic, public health officials did discourage the wearing of masks by the general public, but the motivations were mixed. In retrospect, the primary motivation appears to have been fear that the public, most of whom at the time were at relatively low risk, would buy up all the masks, creating even worse shortages for medical personnel than what was already the case, with the further rationalization that there wasn’t a lot of hard evidence yet that masks worked to slow the spread of this particular novel coronavirus. And, in retrospect, I get it (sort of). After all, in March and April, in my neck of the woods, it was damned near impossible to find toilet paper, and regular surgical masks were exorbitantly priced, even on Amazon, and took a month to ship. Even though I can understand the motivation, in retrospect it’s obvious how much harm this initial reticence caused.

By the time the Surgeon General issued updated advice on masks in April, it was too late:

The original confusion had been a midwife to the birth of the antimask movement. Indeed, it was obvious by mid-March that this message had backfired spectacularly, as Dr. Zeynep Tufekci noted when she wrote about how to “help manage the shortage, the authorities sent a message that made them untrustworthy”:

First, many health experts, including the surgeon general of the United States, told the public simultaneously that masks weren’t necessary for protecting the general public and that health care workers needed the dwindling supply. This contradiction confuses an ordinary listener. How do these masks magically protect the wearers only and only if they work in a particular field?

Second, there were attempts to bolster the first message, that ordinary people didn’t need masks, by telling people that masks, especially medical-grade respirator masks (such as the N95 masks), needed proper fitting and that ordinary people without such fitting wouldn’t benefit. This message was also deeply counterproductive. Many people also wash their hands wrong, but we don’t respond to that by telling them not to bother. Instead, we provide instructions; we post signs in bathrooms; we help people sing songs that time their hand-washing. Telling people they can’t possibly figure out how to wear a mask properly isn’t a winning message. Besides, when you tell people that something works only if done right, they think they will be the person who does it right, even if everyone else doesn’t.

It also certainly didn’t help that the World Health Organization didn’t change its recommendations downplaying the importance of wearing masks until June. (In fact, I’ve long been frustrated at how slow the WHO has been in general to change its recommendations in response to new science.) This was particularly infuriating, given that, as Dr. Tufekci noted, mask use had always been advised as part of the standard response to being around infected people, especially for people who may be vulnerable, WHO officials were wearing masks during their news briefings, and since the SARS experience in 2003 that health officials in many high-risk Asian countries had advised wearing masks. She also pointed out that the messaging at the time also recommended that people who were sick should wear masks to protect others, further noting that, given the increasing evidence of asymptomatic transmission of SARS-CoV-2, the coronavirus that causes COVID-19, such advice would imply that everyone should wear masks when around others.

Indeed, just this Thursday, President Trump himself repeated misinformation about masks and COVID-19 during his televised town hall, mangling and misinterpreting a CDC study. Host Savannah Guthrie called him out for his misinterpretation of the study, leading Trump, in essence, to shrug his shoulders and respond, “That’s what I heard and that’s what I saw”. A week earlier, stories had been published describing how President Trump had blocked the CDC from requiring masks on public transportation.

Messaging screwups early in the pandemic aside, though, what about the “masks make you sicker” claim? Khazan states:

Versions of this advice also suggested that masks could raise the risk of illness. On March 12, Jenny Harries, England’s deputy chief medical officer, claimed that masks could “actually trap the virus.” Therefore, she said, “for the average member of the public walking down a street, it is not a good idea.” (Harries did not respond to a request for comment.)
In fact, the earliest instance of a “masks make you sicker” claim I could find was in a February 27 news article published on a Utah radio station’s website. (Its author did not return a request for comment.) Though the article has since been updated, the original contains the subhead “Wearing a face mask incorrectly might put you at greater risk of getting sick.” The article then quotes a doctor named David Eisenman as saying, “I think people see a mask and they see an illusion of protection.” Though Eisenman’s quote does not quite support the subheading on the article, I reached out to him to see whether he still stands by his interview.

In short, he does not. “These things come back and haunt you,” Eisenman, a professor-in-residence at UCLA, told me. “Science recommendations have evolved. Now I would say that the evidence is very much in favor of masks as an important protector in the spread of COVID-19.”

This is very much like what happens with alternative medicine cancer cure testimonials. Once the testimonial of a cancer patient who chose alternative treatment instead of conventional science-based treatment is published, later information that the patient’s cancer progressed and the patient ultimately died often never find their way into the consciousness of people spreading the testimonial. As Grant Ritchey notes, this is partially due to the anchoring heuristic, in which a person places more significance on the first piece of information they receive than on subsequent pieces of information. In this case, the first piece of information was that mask wearing doesn’t protect the general public. (Never mind that the same message is that mask wearing did protect health care workers.) Add to that some motivated reasoning to cherry pick information, data, and studies that support one’s preexisting point of view and the message from President Trump and others turning the refusal to wear a mask into an ideological signifier, and the recipe for our current disaster of “mask wars” was written.

All of this has led to yet another example of how, once started, pseudoscientific misinformation is almost impossible (if not altogether impossible) to kill. As Khazan puts it:

The “masks make you sicker” idea underscores how online misinformation is like an ocean liner: Once it’s headed in one direction, it’s difficult to turn around. The advice on masks changed seven months ago, but some people have stuck with what experts were saying in the confusing early days. One doctor’s criticisms of masks—which he now recants—live on in Twitter threads. And as people find new ways to share incorrect information, through posts, photos, and videos, social-media platforms are struggling to catch and remove all the hokum. Before long, the conspiracy theories break free of Facebook and infect reality.

My only quibble is that conspiracy theories don’t “break free of Facebook.” They’ve always been free of Facebook. Facebook might be the single most powerful tool in existence to spread baseless conspiracy theories and pseudoscience, but conspiracy theories and pseudoscience spread in parallel in other ways, independent of Facebook. Those other ways don’t just include other social media platforms, such as Twitter, Instagram, Tik Tok, and others, but in society in general. People spread these conspiracy theories among themselves in their social circle, and it also spreads from there. In other words, Facebook reflects and amplifies preexisting conspiracy theories; it generally doesn’t create them. After all, 9/11 conspiracy theories appeared almost immediately after the World Trade Center attacks, even though current social media platforms didn’t exist back then, and the then-embryonic social media consisted of blogs (which were themselves new), Usenet, email lists, and some web-based discussion forums.

Unfortunately, the “masks make you sicker” narrative will likely prove as impervious to reason and evidence as 9/11 Truth, antivaccine, and climate change conspiracy theories that undergird so much science denial.

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Posted by David Gorski

Dr. Gorski's full information can be found here, along with information for patients. David H. Gorski, MD, PhD, FACS is a surgical oncologist at the Barbara Ann Karmanos Cancer Institute specializing in breast cancer surgery, where he also serves as the American College of Surgeons Committee on Cancer Liaison Physician as well as an Associate Professor of Surgery and member of the faculty of the Graduate Program in Cancer Biology at Wayne State University. If you are a potential patient and found this page through a Google search, please check out Dr. Gorski's biographical information, disclaimers regarding his writings, and notice to patients here.