The good women
6:30 am, in a south province of Rome. I arrive at an almost empty coffee shop without my mask. I stay on the doorstep and plead guilty: “I forgot the facemask,” and without getting any closer I add: “Would you make me a milky coffee anyway?”
The woman behind the counter, who’s making cappuccinos for everyone with her facemask hanging from one ear, shakes her head as a sign of great disappointment. The client standing in front of her, who wears her facemask under her chin, chips in and they both shake their head in disgust and contempt for my almost intolerable antisocial forgetfulness.
“Ok, well, what should I do? Shall I leave?” I just ask to know whether I’m going to starve or if I’ll be able to have breakfast one last time- for the grace of God!
The perfect facemask wearing club decides to grace me and allows me to purchase my breakfast, which I eat outside, because it’s known, fresh air is good for you.
So, once outside, I can make a mental summary of the best scenes that I happened to witness recently around this delightful world. I award my mental prize to a man I saw the other day who tried to get on a tram without touching anything and fell disastrously on the floor as soon as the driver hit the break, because indeed he was not holding on to anything.
There was no good reason to help him get back up.
A super good morning to all of you then.
By the way, the milky coffee was shit and the croissant was even worse.
Martina Lavagnini
The year we are going through forces us to reflect on the meaning of alternatives that are only seemingly radical: distance and proximity, claustrophobia and claustrophilia, restriction and freedom. As we approach a way out from the situation of emergency we feel as though we are at a roundabout from which several different roads begin. They are not binary because- as Martina Lavagnini explained in her quick story on cappuccinos and facemasks- the pandemic created a series of “mental postures”, that- as Pier Aldo Rovatti [1] put it- are as different as the personal reflections that arise from the many truths encountered during these months.
Public ethics cannot be delegated to those governing. Furthermore, the “public” aspect of ethics does not get priority over the way of living of individual subjects. Pier Aldo Rovatti
The discussion over the possibility of wearing a facemask for protection from the infection explains the multiple stands that emerged during these months. “The evidence and suitability of the different types of facemasks to prevent respiratory infections during epidemics is modest and has been contested” says Trisha Greenhalgh, practitioner and researcher at the Nuffield Department of Primary Care Health Sciences of the University of Oxford. “However, Covid-19 is a serious disease with no current known treatment or vaccine. The death rate is increasing and healthcare systems are under pressure. Given this is the situation we are facing, looking for “perfect evidence” needs to also leave space for the principle of caution. Masks are simple, cheap and potentially effective. Wearing them (particularly for those showing symptoms) both at home and outside, in situations where meeting others is likely, can have a substantial impact on the spread of the infection and small consequences for social and economic life.”
An important and accurate review was published recently on the Lancet. It was a review of the data available from scientific literature, among which there were 172 observational trials that investigated how physical distancing, facemasks and equipment to protect the eyes influence the diffusion of Covid-19, SARS and MERS in the community (in open and closed social spaces) and in the care homes of 16 countries [2]. A physical distance of at least one metre reduces the risk of Covid-19 infection, but keeping a distance of at least two metres might be even more useful in terms of prevention. The risk is halved with each additional metre. The face coverings and the N95 masks are essential for healthcare workers as they guarantee a greater protection than surgical masks. These could protect citizens from the Covid-19 infection. The equipment protecting the eyes is also important and it can provide further benefits because when wearing gloves or a shield the risk of infection goes from 16 per cent to 6 per cent.
“It should be highlighted that the certainty of data is low for both forms of protection,” explains Holger Schünemann, one of the authors of the review who works at the Department of Health Research Methods, Evidence and Impact of the McMaster University. “This means that the reality might differ substantially from the effect predicted by this study and that depends on the quality of the methodology of the studies utilised in the systematic review. It is important to stress that, even though these measures are followed correctly, none of these interventions offers a complete protection and that other basic protective measures- for example hand hygiene- are essential to reduce the infection”.
Nonetheless, despite the modest quality of data, should the results lead to guidelines changes? “A respirator should be a minimal protection standard for the healthcare workers of the Covid-19 wards,” commented Raina MacIntyre from the Kirby Institute of the University of New South Wales, Australia. “This study should prompt a review of all the guidelines that recommend the use of surgical masks for the healthcare workers who look after Covid-19 patients. Even though surgical masks do offer a level of protection the measures adopted by healthcare staff around health and safety at the workplace should take the maximum priority and apply the principle of caution. Multi-layered respirators and masks are more protective than single-layered masks. This data is crucial to give correct information around the spread of homemade masks made with tissue, many of which are single-layered. A well-designed tissue facemask should be made with a waterproof and multi-layered material that fits the face well. The universal use of the mask would allow to loosen some restrictions in the community, favouring the resumption of activities and protecting people in crowded places and within households”.
In conclusion, there is weak evidence but this should still prompt a change in the guidelines for citizens around the prevention of the infection. This was actually done, to a certain degree, by the World Health Organisation (WHO) as it partly modified its own recommendations.
Should we wear masks during the Covid-19 pandemic? “It is a very, very, controversial matter,” says Paul Glasziou, Director of the Institute for Evidence-Based Healthcare at the Bond University, Australia. “First of all, we could say it’s reasonably evident that facemasks don’t provide much protection. It probably depends on many things but an established fact is that the virus can enter through the eyes, the nose or the mouth and most masks don’t provide any protection for the eyes and just provide a partial protection to the nose and the mouth. However, if we were sick and we all wore masks in set places we could protect other people from getting infected. Therefore the answer is “probably so”. Wearing masks is required only in very limited circumstances so I would say that it isn’t helpful to wear them outside if there is good ventilation, but it might be a good idea in crowded places.
At the beginning of the epidemics the WHO actually discouraged the use of facemasks for the general population but today they seem to have changed their mind. “It was a very complex decision for the WHO,” carries on Glasziou, “and it had to make in order to guarantee the prioritisation of the provision of good quality masks for healthcare workers and the other people who require that type of protection. It is much less clear whether a homemade facemask provides sufficient protection. The systematic reviews leave us really uncertain therefore I think that the WHO found itself in a difficult position. The data on any kind of effect, particularly for masks made with tissue, was weak, and if citizens utilised them correctly there would not be enough good quality masks for everyone, because they need to be disposed of after a single use. The position of the WHO was pragmatic.”
Even though recurring to the opinion of the expert is the safe thing to do, it is risky to let them have the final say.
Donatella Di Cesare
Why do the conclusions of Glasziou’s systematic review [3] seem to differ from those of McMaster’s work? The answer of Glasziou himself is, “Well, let’s look at the commonalities”. “Holger’s conclusion is that there is low quality evidence, particularly around assessing the observational studies that were conducted. These are the same studies that claimed there were benefits while randomised trials suggest that any benefit is minimal. We find ourselves facing a dilemma and the issue is around what to do when the evidence we find is weak. I believe we need to find a balance: we should think about the disadvantages of wearing masks such as their poor adherence to the face, how difficult it is to wear them for a prolonged time, the continuous tendency of the person wearing them to touch their face and ending up infecting themselves by touching their eyes. Then, when balancing the low quality evidence and the negative aspects that are intrinsic to masks, we need to consider in which circumstances their use is recommended, such as in crowded places, indoor or on public transport. However, if you’re going out for a picnic with your friends there is no reason to wear a facemask. There is an urgent need for research, for example on the face shields made of transparent plastic that have the advantage of being reusable and that could be made available to the public much more easily than surgical facemasks.”
Reflecting on a theme like this makes us reflect on a reality that we came across by chance during these months: the different perspective of experts and researchers. The former almost invariably provide certainties, under the pressure of the public opinion- that is anxious to know but also demanding sure responses. The latter know that “the result of one’s research is always partial and temporary” [4]. The dialectics of these stands- as long as they are evidence-based and interpreted fairly and honestly- can be considered as an opportunity, an added value for knowledge.
References
[1] Rovatti PA. In virus veritas. Milano: Il Saggiatore, 2020.
[2] Chu DK, Akl EA, Duda S, et al. Physical distancing, face masks, and eye protection to prevent person-to-person transmission of sars-cov-2 and covid-19: a systematic review and meta-analysis. Lancet 2020;S0140-6736(20)31142-9.
[3] Jefferson T, Jones M, Al Ansari LA, et al. Physical interventions to interrupt or reduce the spread of respiratory viruses. Part 1-Face masks, eye protection and person distancing: systematic review and meta-analysis. MedRxiv 2020.03.30.20047217.
[4] Di Cesare D. Virus sovrano. L’asfissia capitalista. Torino: Bollati Boringhieri, 2020.
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