By Lambert Strether of Corrente.
Let’s get the engineering stuff out of the way first, because masking is too important to be left to the medical community. Covid is airborne (a.k.a. aerosol transmission); people infect each other with Covid via “shared air”, which floats like cigarette smoke. Covid is airborne in hospital settings. Masks work to prevent airborne transmission[1].
* * *
Mass General Hospital (Mass General, MGH) is Harvard Medical School’s teaching hospital. MGH is ranked #8 nationally, #1 in Massachusetts. (Mass General is also part of an corporate moloch known as Mass General Brigham, which is “the dominant, tax-exempt academic hospital organization in Massachusetts with $16 billion of annual revenue“). As such, MGH is deeply interlocked with the Massachusetts political, financial, and NGO elites. As a teaching hospital, it exerts enormous influence on health care policy and practice through its network of academics, graduates, researchers, etc. I also have MGH to thank for saving my eyesight, when I had a detached retina many years ago. (MGH also spawned Rochelle Walenksy. I’m not sure if that evens out or not.)
MGH has announced it will change its masking policy on May 12 (four days from now):
With the end of the COVID-19 Public Health Emergency, @MassGenBrigham will end universal masking at all our hospitals, clinics, and other facilities starting on May 12, 2023. Learn more: https://t.co/zAuMrcnlNm pic.twitter.com/snDkTf54aN
— Mass General Cancer Center (@MGHCancerCenter) May 5, 2023
Here is some of the press coverage:
Sadly, MGH’s announcement is disingenuous, and the press coverage is wrong. Here is actual policy. And here are its two key aspects from the patient’s perspective:
As you can see, the patient cannot even ask for staff (doctor, nurse, radiologist, anyone) to be masked; there is to be no accommodation for anyone, even the immunocompromised.
This policy is not medically justified: I mean, imagine a staffer is coughing. Patients aren’t allowed to ask them to mask?[2] Further, the policy mandates one-way masking, which permits more infection than two-way (universal). This policy is wrong for everyone, even if it endangers the immunocompromised most. Covid spreads asymptomatically; it is not possible to know if a staffer has it or not. Further, Covid is airborne and spreads like cigarette smoke; you can catch it from a cashier, or someone passing in the hall, just as well as from a doctor. Masking should be universal in the facility. Therefore, for a percentage of patients, on any given day, MGH is mandating infection.
This policy is not medically justified: Double-masking wrecks fit, as MGH — in the person of Erica Shenoy, who we will meet immediately below — itself admits[3]:
It is important to note that the CDC does not recommend wearing two disposable masks or using a disposable mask over a cloth mask. Neither of these approaches improves the function of the mask in a meaningful way…. The CDC does not recommend wearing two disposable masks, as that does not improve fit. They also stress not wearing more than one KN95 mask, or a mask over a KN95.
MHG is requiring in 2023 exactly what they deprecated in 2021. Here again for a percentage of patients, on any given day, MGH is mandating infection, as we see from this telling anecdote. Shenoy doesn’t know a mask from a hole in the ground:
“If you are worried about compromising the seal you should remove your home face covering and wear the facemask provided.”
i.e. I should remove my N95 and wear a surgical mask for a better seal.
I replied to both her and @ericashenoy explaining this made no sense. I was ignored
— Nurit Baytch (@NuritBaytch) April 19, 2023
How did a major teaching hospital end up mandating infection? Well, that would require more insight into the reactionary mossbacks running the institutional aspects of Hospital Infection Control than I have[4]. What I can say is the first and corresponding author of a key paper creating the permission structure for abandoning universal masking in hospitals — and the consequent addition of Covid patients to the already horrific numbers on Hospital-Acquired (nosocominal) Infection — is none other than Erica Shenoy, Medical Director of Infection Control for Mass General Brigham. First, I will look at Shenoy’s paper. Spoiler alert: It’s bad. Then, I will look at the ADA lawsuit filed against MGH: good, but not great.
The Paper
Shenoy’s paper is from the “Ideas and Opinions” section in the Annals of Internal Medicine, which KLG regards as “authoritative”: “Universal Masking in Health Care Settings: A Pandemic Strategy Whose Time Has Come and Gone, For Now” (“for now,” is rich. As if these goons would ever allow masks back). The paper has in essence two reasons why universal masking should be abandoned. First, basically, “things are better now,” due to better treatments, lower mortality, “endemicity”, and so forth. Second, masks interfere with the delivery of care. I asked KLG to review the first aspect of the paper; I will review the second.
Here is the key paragraph for Shenoy’s first claim:
[T]he context and conditions of the pandemic have changed dramatically and favorably since masking requirements in health care were initially adopted… The burden of SARS-CoV-2 has been mitigated over time through access to testing, substantial population-level immunity providing durable protection against severe disease, a series of less virulent variants, and widespread availability of medical countermeasures, which in combination have resulted in decreasing infection mortality rates.
Here is a lightly edited version of KLG’s response:
This editorial is on the surface very well argued in the leading journal devoted to internal medicine. But other conclusions may rightly differ from those of the authors. They focus on “contextual factors” in the transition of mortality rates from high to moderate to lower to low during the pandemic. All well and good. But one doesn’t really know what to think of “widespread access to therapeutics.” Paxlovid? The evidence is still out on that one (I saw Paxlovid rebound in a close colleague, and it was awful) and other antivirals are still in the pipeline somewhere, one would hope…. An effective vaccine to coronaviruses is still a unicorn and likely to remain so.
As far as “improved vaccines” targeted properly to those most at risk, really? Where and what? Regarding testing, most tests are now antibody self-tests at home with no reporting requirement. Someone with a “mild” case who needs to work right now to live, is likely to be a spreader, and the case in his victims may not be mild.
While the concentration on mortality seems reasonable, this may have declined due to the culling effect of the first wave (a harsh but a reasonable assumption) and improved clinical management of a novel disease. I saw no mention of long covid or the effects of repeated infection on the health of those who get COVID-19 three, four, five, and more times. Endemic does not mean innocuous. HPV is endemic and due to this virus, I spent much of 2022 dealing with the sometimes very challenging consequences of exposure to HPV.
I guess it’s a good thing for Shenoy, then, that this is an opinion piece. Or maybe it’s just an idea, and a bad one. I really wouldn’t know.
Here is the key paragraph for Shenoy’s second claim. Since this is yellow wader-level, er, material, I’m going to add some letterered notes, thus “[A]”:
Maintaining masking requirements for [Health Care Personnel (HCP)] during all direct clinical encounters[A] may marginally reduce[B] the risk for transmission from HCP to patient or from patient to HCP. Those potential[C] incremental benefits, however, need to be weighed against increasingly recognized[D] costs. Masking impedes communication, a barrier that is distributed unequally across patient populations, such as those for whom English is not their preferred language and those who are hard-of-hearing and rely on lip reading and other nonverbal cues[E]. The increase in listening effort required when masks are used in clinical encounters is associated with increased cognitive load for patients and clinicians (5)[F]. Masks obscure facial expression; contribute to feelings of isolation; and negatively impact human connection, trust, and perception of empathy (6,[G] 7[H]).
Before going further, I should point out that today masking by staff is common in Asian hospital settings. Therefore, all of Shenoy’s claims are negated for almost half of humanity. If I were so-minded, I’d call out Shenoy for being Eurocentric, or colonialist, or even racist. To the detail–
[A] Shenoy — it seems hardly possible — seems not to recognize that Covid is airborne, spreads like smoke, and is present everywhere, not merely in direct clinical settings; that’s why masking needs to be universal throughout the facility.
[B] Nice spin on “may marginally reduce.” But doesn’t this claim deserve a footnote? Where were the editors on that? See at engineering, the first paragraph.
[C] More spin. The benefits of masking are real and demonstrable. See again at engineering. See also this useful thread from Trisha Greenhalgh.
[D] “Increasingly recognized” by whom? When? In what publications? How on earth did the editors let a bare assertion like this pass?
[E] So make accommodations for them. Under, say, the ADA?
[F] Footnote (5) is “Face mask use in healthcare settings: effects on communication, cognition, listening effort and strategies for amelioration“, Cognitive Research: Principles and Implications (2022). N = 243, some hearing impaired, some not. Self-reported Facebook survey. Assuming all the “effects” are in fact clinically significant — I don’t — Shenoy is simply dishonest tendentious in that she erases the “strategies for amelioration” section of the paper, from which I quote:
To better understand how patients feel medical appointments could be improved, patients rated the following eight rehabilitative strategies from least helpful to what is most helpful during clinical appointments… A majority (57.5%) of patients selected written or visual instruction for themselves and/or their family members to be the most beneficial to have during their medical appointments, followed by including a family member into the appointment remotely if unable to attend by phone/video call (32.5%), microphones worn by the healthcare provider/Assistive listening technology (25%), more frequency phone/email follow-ups with your healthcare provider (20%), speech-to-text application (17.5%), longer appointment times (17.5%), additional follow-up appointments (15%), and support groups (5%).
Doesn’t all that sound like something a humane medical system should do? And isn’t it the least bit sketchy that Shenoy would rather infect patients by eliminating universal masking than — hear me out — ask doctors to speak louder or write things down?
[G] Footnote (6) is “Effect of facemasks on empathy and relational continuity: a randomised controlled trial in primary care”, BMC Family Practice (2013). N = 1030. First, the study is from Hong Kong. I would be very surprised indeed to find that HCWs in Hong Kong did not wear masks — search is completely useless on this, being contaminated by the mask wars — if only because of the lingering effects of SARS. If they do, that means they consider (as they ought) that patient safety is their primary concern. Second, “Amongst the wealth of literature analyzing non-verbal behaviour and its effect on the doctor-patient relationship, this is the first in exploring the impact of concealing facial expressions on the patient’s perception of empathy.” I absolutely deny that masks “conceal facial expression.” That’s a hypothesis, not a fact. The eyes are part of the face, and capable of communicating a full range of emotion and empathy. Third, “In this large randomized controlled trial, we found that the wearing of facemasks by doctors had little effect on patient enablement and satisfaction but had a significant and negative effect on patients’ perceptions of the doctors’ empathy.” So if the patients were satisfied when the doctor was masked, does empathy matter so much? Isn’t “patient satisfaction” a key metric for hospital administrators these days? Finally, this all boils down to “Let me see your smile.” Feh.
[H] Footnote (7) is “Morally Injurious Experiences and Emotions of Health Care Professionals During the COVID-19 Pandemic Before Vaccine Availability” JAMA (2021). To begin with, plenty of moral injury was due to there not being enough PPE, including masks, a situtation for which Hospital Infection Control is directly responsible (“I felt as though we were being ‘offered up for slaughter’ by having to stay in a COVID filled room with questionable PPE”), a moral injury Shenoy oddly omits to consider. Second, confounders: “masks and social distancing contribute to feelings of isolation. Many stated that it was stressful adapting to social distancing measures, such as having to “stand farther away from a colleague than previously” (respondent 11), not being able to see the entirety of facial expressions, or even recognizing coworkers in the hallway. The close interactions that would have bonded coworkers together are restricted, and many outlets for stress have been suspended.” Nowhere in the study are masks singled out as causing any sort of injury whatever. Third, I can only classify Shenoy whinging about the “moral injury” while establishing a policy that mandates patient infection as chutzpah. If not worse.
Finally, one cannot help but contrast the flimsiness and tendentious quality of Shenoy’s work product with the braying for RCTs that assails aerosol scientists and mask advocates. Shenoy’s work is mediocre at best; sloppy and dishonest at worst, and should form no basis for a policy change at a major teaching hospital, let alone a policy change that puts patients at risk.
Let us now turn to the lawsuit that hopes to prevent Shenoy’s dangerous bunkum from coming to pass.
The Lawsuit(s)
First, from another part of the Harvard forest, the question of liability. From “Hospitals That Ditch Masks Risk Exposure“:
Ending routine masking in hospital settings is a dangerous move. It puts patients and staff at risk for infection, and its potential long-term effects. It also exposes hospitals to the risk of liability.
Hospitals have a common law duty to act reasonably. If they unreasonably expose patients to risk, and the patients are harmed as a result, hospitals may be liable for damages. The result: patients who can show that it is probable that they were infected with COVID-19 in a hospital, and that they would not have been if the hospital had taken reasonable measures to protect them, may be able to successfully sue hospitals for damages.
Further, CDC may not be able to run interference for them:
The big question is what does it mean to act “reasonably” in a world in which COVID-19 abounds and remains a leading cause of death, including for children. Over the past century, courts have developed a variety of approaches to figuring out the bounds of reasonableness. In determining whether a precaution is “reasonable,” modern courts commonly consider the relative costs and benefits of taking that precaution. Where an individual causes harm because they fail to take a cost-justified precaution, they may be found negligent and required to pay for the damages they have caused.
Requiring masks in direct patient care settings is a prime example of a cost-justified precaution. Masking is a simple, effective, and low-cost measure that hospitals can take to substantially reduce the spread of COVID-19. And the benefits are significant in hospital settings. Hospitals concentrate people who, as reflected in the conditions that bring them to the hospital, are both more prone to infection and more likely to face serious consequences if infected. Moreover, both healthcare providers and patients are known vectors of transmission in healthcare institutions.
MGH has deep, deep pockets; $16 billion deep. I hope some clever lawyer, even now, is working out how to dig in and collect a packet. But that’s not the instant case, which is an ADA suit.
My first Patreon lawsuit — “Mass General Brigham wants a blanket ban on staff 😷 disability accommodations. I think that’s unlawful” — but never mind that. From Mathew Cortland, not actually a lawyer (but you don’t need to be one to file an ADA complaint):
In my view, filing before Monday morning is incredibly important because we are rapidly careening towards May 12th [when MGH’s new policy goes into effect[. So, while this is not the document I would have produced if I had more time, it will have to suffice.
I will now quote a great slab of text from Cortland’s complaint. MGB is Mass General Brigham, Mass General’s parent entity. Notes are omitted. Again, I have added notes thus: “[A]”:
In the context of SARS-CoV-2, masks serve two primary functions: 1) respiratory protection and 2) source control.
Respiratory protection refers to the mask filtering viral particles from the air as the mask wearer breathes in. A perfectly fitted N100 mask (also known as a “filtering facepiecerespirator”), would be expected to filter 99.97% of airborne particles. Respiratory protection, therefore, can be thought of as “my mask protecting me.”
Source control refers to the mask blocking transmission of infectious virus when the mask wearer talks, exhales, coughs, or sneezes[A]. Source control is the function whereby the mask blocks the mask wearer from spewing infectious virus in the air or onto a nearby surface[B] or person. Source control, therefore, can be thought of as “my mask protecting you.”
CDC has published a document titled “Scientific Brief: SARS-CoV-2 Transmission” which includes a key component of the scientific rational for a disabled patient asking health care staff to mask. CDC says, in relevant part, “[t]he principal mode by which people are infected with SARS-CoV-2 (the virus that causes COVID-19) is through exposure to respiratory fluids carrying infectious virus. Exposure occurs in three principal ways: (1) inhalation of very fine respiratory droplets and aerosol particles[C], (2) deposition of respiratory droplets and particles on exposed mucous membranes in the mouth, nose, or eye by direct splashes and sprays, and (3) touching mucous membranes with hands that have been soiled either directly by virus-containing respiratory fluids or indirectly by touching surfaces with virus on them.” Id.
With regard to the first mechanism, inhalation, CDC says inhalation “[r]isk of transmission is greatest within three to six feet of an infectious source where the concentration of these very fine droplets and particles is greatest[D].” Id. Even a mask that doesn’t provide complete source control, e.g. a surgical mask, will decrease the concentration of infectious very fine droplets and particles within three to six feet of an infectious source.
With regard to the second mechanism, CDC describes “deposition of virus carried in exhaled droplets and particles onto exposed mucous membranes (i.e., “splashes and sprays”, such as being coughed on)” and says that risk of deposition transmission “is likewise greatest close to an infectious source where the concentration of these exhaled droplets and particles is greatest.” Id. Even a mask that doesn’t provide complete source control, e.g. a surgical mask, will block splashes and sprays from an infectious source.
In a large health care system such as MGB, there are almost certain to be health care staff who are actively infected with COVID-19 but who are asymptomatic and unaware of that they are COVID-19 positive.
Disabled patients who are at higher risk from COVID-19 have the right to ask MGB staff to mask[E] as a reasonable modification to MGB’s staff masking policy in order to access health care provided by MGB. At least one federal district court has found that requiring mask usage can be a reasonable modification on the basis of disability. Seaman v. Virginia, 593 F. Supp. 3d 293. Instead, MGB seeks to impose a blanket ban on requests for reasonable modification on the basis of disability to its staff masking policy. MGB is doing so in violation of federal disability civil rights law.
[A] Or breathes.
[B] Fomite transmission of Covid is not supported in the literature (though China believes in it, perhaps rightly).
[C] This verbiage is CDC’s awkward attempt to reconcile droplet dogma and aerosol transmission. I don’t recall epidemiology on (2) “splashes and sprays” and (3) touching mucous membranes. The former is droplet dogma, the latter is fomite transmission.
[D] Wrong. Covid is airborne, and moves through the entire hospital facility.
[E] They do, but the limitations of the ADA approach is that it does not get us to universal masking.
I’m a little concerned that this complaint could win the battle and lose the war if (A) the abhorrence — the visceral hatred and denial — of airborne transmission shared by both CDC and Hospital Infection Control becomes enshrined in any sort of citable precedent, and (B) masking becomes, well, a “scarlet letter” for the disabled — even if they do become safer for it, as they will — but the not-yet-disabled go unprotected. At a bare minimum, everybody should be able to ask staff to mask, and double-masking would be deprecated. However, I’m a maximalist, and I think masking should be universal and a cultural norm. An ADA-centric approach, even if important tactically, cannot get us to that point.
Conclusion
Something is very, very wrong in Hospital Infection Control. From the San Jose Mercury News, “Opinion: California health care providers’ retreat from COVID masking is shameful“:
When the California Department of Public Health last month lifted mask mandates in health care settings, it didn’t even cross my mind as a physician and CEO of Roots Community Health Center to drop masks in clinics I oversee in the East Bay and San Jose.
The absence of a public health order never determined health care facility policy before, so I was shocked that several health systems dropped masks the moment they stopped being required. I did not need to be mandated to do the right thing for patients and staff at the onset of the pandemic, and the removal of a mandate did not erase my duty to protect and advocate for essential frontline workers and marginalized community members.
With the swift unmasking, I was not surprised by the COVID outbreak within about two weeks at Kaiser Permanente’s Santa Rosa Hospital and the facility’s quick return to masking. We should all be dismayed that staff and patients were allowed to be sickened despite the availability of masks to prevent the unnecessary harm.
Organized medicine’s retreat from masking is shameful. It is not data driven, and there is no experiential evidence to support the decision to de-mask. That is why hospital-issued statements fail to cite science for their policy changes. Instead, faceless committees issue platitudes about being in a “new phase” and reference available treatments.
But they paper over the very problem they are creating: In what universe is it ethically appropriate for health care institutions to infect their own patients with SARS-CoV-2 when masking so effectively reduces its spread?
That’s a very good question. Sadly, nobody in MGH’s Infection Control Department seems able to answer it. Except, I suppose, with a shrug, a sneer, and a demand to “Let me see you smile!”
NOTES
[1] There is rough hierarchy of masks according to the seal they create, starting with “Baggy Blues”, (surgical masks), through ear-loop respirators (KN95), headstrap respirators (N95, ideally fit-tested), and ending with full-on Darth Vader masks. (I’m eliding N95 and KN95 because the market has so confused them; there also many international standards). Protection should, of course, be layered, masks forming one layer.)
[2] Examples of coughing and sniffling staffers who are maskless, or with a “Baggy Blue” sagging beneath their chins, are so numerous on the Twitter as to form a genre.
[3] It’s been awhile, but I would have thought we moved beyond cloth masks by March 2021. It’s also noteworthy that nowhere does MGH recommend that people use the highest quality mask, and while they write: “Patients and visitors to Mass General will be issued a single, hospital-grade medical mask. This mask has multiple layers and meets hospital standards” they very explicitly do not say these are N95-level. (So-called “hospital-grade” masks, which fit poorly, are probably optimized for droplet dogma, not airborne transmission.
[4] At this point we remember that Dr. John M. Conly, corresponding author of the infamous “fools gold-standard” Cochrane study, also made his way upward to his perch at WHO from the primordial slime of Hospital Infection Control in Alberta, Canada.
