For Older adults in Nursing Homes - Masks are a Prison within a Prison
We need to start honestly and openly weighing the costs of making the elderly in nursing homes permanently more confused, isolated, and cut off from their carers due to neverending masking
Let’s Talk About Masks in Nursing Homes
In the United States, if you live in a regulated, certified assisted living facility or nursing home - you are in 2022 largely or completely still surrounded by caregivers in procedure masks. Prior to 2020 - this is what you used to see:
Now this is all nursing home residents have seen since then:
Why is this important?
First of all - I cannot tell you how many times I have heard since 2020 that “masks are no big deal.”
I cannot emphasize how completely privileged such a statement is.
My clients are nursing home patients. At any given nursing home in the USA - estimates are between 50-70% of the patients have dementia, like Alzheimer’s disease. One of the typical symptoms of dementia is language deficits, meaning they will need to depend much more on nonverbal communication (e.g., facial expressions, etc.) to understand the speaker than you or I do.
Also widespread in nursing home populations is hearing problems, and deafness. That also means that they need to try and read nonverbals, as well as read lips in order to understand their carers better. Masks directly interfere with this as well.
The fact is - the idea of so-called “universal masking” - or the idea of having everyone, caregivers / nurses, residents, etc. always wear masks (whether symptomatic or not) to “prevent the spread of COVID,” I believe, has a significant number of very serious risks to my nursing home patients. I believe that masks in nursing homes
Makes instances of verbal communication more difficult, frustrating, and therefore shorter between residents and carers
Makes communication less meaningful
Increases a sense of isolation and loneliness in residents
For residents / older adults forced to wear them:
it obscures vision, and for those already prone to falls, may increase their risk further. For those in wheelchairs, it simply makes their world more confusing and difficult to navigate - particularly with those with preexisting vision problems or partial blindness.
for those with any level of dementia (about 70% of my nursing home residents), they are unlikely to wear them properly, even if they are “compliant” (acquiescent, at least) - these masks are drooled on, half in their mouths, their noses showing, etc. - they simply don’t wear them even plausibly in a compliant manner
for these older adults who have bad oral hygiene or worse - have maybe some thrush or borderline or worse oral-fecal contamination (yes, this happens in dementia - they don’t wash their hands, they touch places they shouldn’t and then touch their mouths) - whatever nasty that’s brewing in their mouths end up multiplying and growing on these masks that they can wear sometimes for hours1
Early in 2020 when the relative lethality and mode of transmission of COVID was unknown, and there were no vaccines, and the disease itself was at its most lethal - costs like these seemed to make perfect sense to bear, particularly given the relative risk that older people bear when it comes to COVID-19.
I think in essence - given that my nursing home patients are virtual prisoners (not allowed to leave the facility for any reason) - “universal masking” represents a prison within a prison.
“The wise man is one who, knows, what he does not know.”
― Lao Tzu, Tao Te Ching tags: wisdom-for-living
GeroDoc’s Epistimology as Regards Nursing Home Care (not just about masks)
After having worked in the area of geriatrics and long-term care for going on 20 years now, I’ve come to truly appreciate – and understand – the value of relying on properly experienced, educated, and qualified experts. A nursing home only truly works when we all understand the bounds of our respective disciplines and then work together as a team to solve the complex problems our residents face. Long-term care is about interdisciplinary care. We are only an effective team when we work together.
That being said - I am by no means at expert in infectious disease, virology, or in particular – the physics and science of Personal Protective Equipment (or PPE). This is typically the purview of professionals who specifically specialize in the area of healthcare-related Occupational Safety and Health (when it comes to the issue of PPE and viral or other pathogens, that is).
Here we go anyways. Let’s talk about masks.
Masks are a complicated, multifaceted subject. My take is that anyone who at any point in a discussion says without elaboration that “masks work” or “masks don’t work” shouldn’t be listened to. Period.
Before we get into things let’s start with some defining of terms and the basis of the discussion.
First – there’s cloth masks. These are masks not designed for medical use, designed to be washed and reused, and typically made of simple fabrics). I’m not going to spend a lot of time talking about them - mainly because there’s generally nothing particularly useful about them aside from the social aspect.
One thing to keep in mind, though - even though masks are basically useless (or, as the notorious COVID grifter Leana Wen called them “face decorations”) - nearly every mask mandate in the USA is a cloth mask mandate (meaning - cloth is acceptable). Which, to my mind, call into question the utility of any of these mask mandates - ever.
Moving right along - then there’s N95 masks. Unlike procedure masks, when worn properly, N95s are designed to provide an airtight seal around the face and by design filter air through a series of woven polypropylene fibers.
N95 masks also aren’t masks per se - they are classified by OSHA as respirators.[2] They also require a pretty involved process called “fit-testing” in order to use them effectively - a process that an overwhelming majority of the public, when they use them, simply don’t do. At my nursing home, we only use N95s during times of active disease outbreak in our unit around affected individuals.
When I’m talking about masks in this article, I’m mostly talking about so-called procedure masks – or what lots of people call surgical masks. These are the masks (familiar to basically all of us now) that prior to 2020 were seen almost exclusively on surgeons operating in a theater, are made typically of a combination of polypropylene (plastic) threads and paper, and are worn with ear loops, and do not provide a seal around the face where they attach (e.g., they will by design tend to ‘vent’ around the face as the wearer breathes).
A Brief History of Procedure / Surgical Masks
I highly recommend readers read carefully the literature review by Charlie Da Zhou and his colleagues at the University of Oxford, published in 2015. While still a current article – it’s far enough out from the current zeitgeist of institutional and bureaucratic obsession with casual, public mask-wearing to give a pretty sober history and overview of how and why the procedure mask came about and was developed, and what procedure masks do and can’t do well.
The history is kind of interesting. Prior to the introduction of aseptic surgical techniques, the approach of covering surgeons faces during surgery was instituted (first described, apparently, in 1897) in the form of placing apparently a single layer of gauze over the mouth. Initially instituted as a method of “protect(ing) the patient from contamination and surgical site infection” coming from the mouth of the surgeon, it was later found that, well, procedure masks don’t really do that. The authors go on to say (page 224):
”Intuition would suggest that facemasks offer a physical barrier preventing the emanation of droplets from the oral or nasal passages and therefore satisfy the efficacy requirement of the evidence ladder. However, there are a number of different hypotheses as to why this may not be the case. ‘Venting’ is a phenomenon whereby air leaks at the interface between mask and face which can act to disperse potential contaminants originating from the pharynx. The accumulation of moisture, during prolonged usage, may exacerbate this problem by increasing resistance to air flow through the filter itself. Moisture accumulation is also thought to facilitate the movement of contaminants through the material of the mask itself by capillary action. These bacteria can subsequently be dislodged by movement. Friction at the face/mask interface has also been demonstrated to disperse skin scales which can further contribute towards wound contamination.”
In terms of what is quantifiable - procedure masks do seem to prevent splashes from the surgical wound site into a surgeon’s mouth and nose - apparently providing up to 24% risk reduction depending on the study. This is no small thing - apparently obstetric surgeons have a huge problem with this (68% occurrence in c-section surgeries).
However - the authors go on to say (p. 226):
Despite clear evidence that facemasks act to protect the theatre staff from macroscopic facial contamination, there are studies to suggest that they fail to protect surgeons from potentially hazardous sub-micrometre contaminants. This corresponds roughly to the size range of infectious bacteria while viruses are even smaller. Therefore, the protection that masks confer in the form of macroscopic facial contamination may not necessarily extend towards any microscopic infectious agents present within that contamination.
So - while surgical masks do prevent backsplashes to surgeons faces. What they don’t seem to do is provide any protection to surgeons from airborne illnesses passed from the patient to the surgeon - nor do they seem to appreciably prevent the spread of infection from the mouth of the surgeon into the patient’s open wound.
This may seem shocking based on the almost messianic fever to which many public officials (including doctors) seem to urge people to wear masks - but the phenomenon of fervent public masking, and the public exhortation of mask-wearing by prominent officials such is far more of a social craze of sorts, a crowd madness, even - than it is based on anything concrete about how (procedure) masks were developed or used or the science (pre-2020).
For more details:
I recommend any of Megan Mansell’s stuff BTW - she’s an industrial hygienist by trade (these are the people, BTW, whom physicians go to if they wish to be prescribed personal protective equipment, or PPE). I’ve chatted with Megan as well as another experienced industrial hygienist and the bottom line is, short of a properly fitted and religiously worn N95 mask, the bizarre worship of masks as source control of viruses makes zero sense from the perspective of aerosol and particle physics.
Directly Testing Masks (short of fit-tested N95s) Show They Fail Again and Again as Source Control
In the following case of Landry et al., in a 2022 article in The Journal of Infectious Diseases, the authors took as direct an approach as possible - they tested the efficacy of cloth, procedure, and fit-tested N95 masks by putting them on subjects, then literally spraying them in the face with actual, aerosolized viruses. They then measured the result:
Significant virus counts were detected on the face while the participants were wearing either surgical or N95 masks. Only the fit-testPASSED N95 resulted in lower virus counts compared to control (P = .007). Nasal swabs demonstrated high virus exposure, which was not mitigated by the surgical/fit-testFAILEDN95 masks, although there was a trend for the fit-testPASSED N95 mask to reduce virus counts (P = .058).
So yes, again - this may be a shock to a lot of people. And in fact many of you may want to, after reading my article - search for alternate forms of evidence that supports the use of surgical masks to “prevent spread of COVID” - in fact, they’ll probably find a lot of evidence easily available (most famously the “Bangladesh study”) that seems to support the use of procedure (and cloth) masks as source control. I’m also perfectly aware that the CDC (still!) supports this idea. But based on the physics of procedure masks and cloth masks themselves - it still makes no sense:
But - I’ll grant - it’s still possible that even though we can’t explain how masks slow transmission of COVID via simple physics - mask wearing may still slow COVID transmission.
How?
If Masks Work - They Work by Making People Interact Less
Although there’s been a few articles on mask-wearing in children in terms of their ability to slow viral transmission, this one from 2006 struck me as very relevant. I like it because it’s a qualitative study. More than just anecdotes and definitely a systematic attempt at observation and quantification, but also less abstract than the number-obsessed, “physics-envy” approaches of quantitative behavioral science, sometimes qualitative studies do the best job of capturing what’s really going on. In it, the writer tried to study what happened when Chinese schools “locked down,” enforced social distancing, and required schoolchildren to wear masks (which is, by the way, exactly what goes in my “nursing home prison” to this day):
One of the most dramatic changes noticeable was the decrease in social interaction among children. Children experienced discomfort when talking while wearing a mask and teachers and students could not read each others’ facial expressions because of the masks. Children’s desks were moved into rows and they were not allowed to change seats during the day. Group size was decreased and there was less interactive teaching. There was an increase in solitary play and children were not allowed to share toys and physical contact among children was prohibited.
The true nature of why masking “works” was famously articulated by Pulitzer Prize winning journalist Laurie Garrett, she reveals the real reason why “masks work”:
There’s only a couple of countries that have ever really done large-scale studies to try and figure out what might work. Japan, it may not surprise you, is one of them. In one of their large studies they basically showed that the masks, it seemed like the major efficacy of a mask is that it causes alarm in the other person and so you stay away from each other. And that’s what I think happened with SARS. When I was in the SARS epidemic I saw everywhere all over Asia people started wearing these masks, and it is alarming, when you walk down the street and everyone coming toward you has a mask on, you definitely do social distancing, you definitely—it’s just a gut thing. But did the mask really help them? Did the mask keep the virus out? Almost certainly not. If the virus was around their face, the mask would not have made a difference.
To be fair, since this interview, she’s since tried to walk back what she’s said, essentially saying that due to the complete novelty of COVID, this has changed, and in fact - procedure (and I guess, cloth) masks do prevent COVID spread. “The science has changed,” or something… although it’s not clear what.
Most distressing to me though - I don’t think this is true. In fact, I think I’d add one more effect of masks in nursing homes to the bullet-point list I started above….
Masks make carers less likely to engage in beneficial physical contact with residents (like a handshake, a comforting hand on the shoulder, etc.) - by sending the implicit social message that contamination is an everpresent danger.
Masks are a prison within a larger nursing home prison for older adults.
And for the life of me, I’m at this point convinced it’s slowly killing them.
It needs to stop.
[1] Interestingly, cloth masks continue to be in widespread use throughout the USA and elsewhere, despite the fact they are probably next to useless as PPE even under the best of circumstances, and medical-grade masks are no longer in short supply. It probably doesn’t help that mask mandates in the USA and elsewhere (outside of medical settings) continue to overwhelming regard cloth masks as acceptable – which then inadvertently leads much of the lay public into to regarding them as effective.
[2] By the way, according to the US FDA (and I believe the Occupational Health And Safety Administration as well) means that N95 masks are not designed to be use by children (under 12s).
This point was suggested to me by Megan Mansell