I was recently preparing a medical talk and found an archived photo from the Spanish influenza pandemic of 1918. In the picture, a nurse was wearing a white, well-fitted mask. The caption on the photo instructed that one must “wear a mask like the one shown in illustration” to avoid the flu.
Americans at first took that advice seriously, especially in the initial peak of the flu epidemic. Then behaviors became spotty and short-lived; emotional exhaustion set in. Critics said that mask-wearing was an infringement on individual liberties, and some American cities rebelled against them. In 1919, as part of the Anti-Mask League, over 2,000 people gathered in San Francisco to protest masks. Ultimately, San Franciscans bore the heaviest brunt of the flu pandemic, with over 45,000 sick and 3,000 dead.
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For the past 15 months, we have suffered through a new pandemic and borne witness to another national mask debate — one, unfortunately, not always driven by scientific evidence. As a physician and public citizen, I support the Centers for Disease Control and Prevention’s scientifically-driven guidance on lifting mask requirements — one that I hope will be joined by a further loosening of restrictions as more Americans become vaccinated. But just as it is critical for us to follow scientific evidence in putting away masks for now, it is equally important to pause, take stock of what we have learned about masks to date, and ask ourselves if there is evidence to support select mask-wearing in our future.
Public health experts agree that mask-wearing over the course of the COVID-19 pandemic has saved hundreds of thousands of lives and, if employed earlier, could have saved more. As a primary care physician at a safety net hospital in Massachusetts, a state where mask-wearing has been highly adopted, I’ve been grateful for this simple public health measure. This layer of protection for my patients — many of whom were more vulnerable to the ravages of COVID-19 as a result of deeply entrenched and structural health, social, and racial inequities — was often the only thing standing between a job and the hospital.
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But masks have not only protected us against COVID-19 this year. They have also prevented deaths from two other sometimes deadly respiratory illnesses: flu and respiratory syncytial virus. Two years ago, the CDC reported 38 million illnesses and 22,000 deaths attributed to flu. During the same months of last year, however, there were just over 1,000 reported cases and a handful of deaths from influenza. This despite a six-fold increase in testing at public health labs. Similarly, RSV typically hospitalizes 58,000 children and 177,000 adults a year and kills 14,000. This past year? Almost none. While social distancing, hand-washing, and the flu vaccine certainly played a role, public health experts agree that it was the high level of mask-wearing in many states that made a critical difference in averting the yearly toll of nearly 36,000 deaths.
As we begin to reimagine our future, we know that gathering safely again with our loved ones is a key part of our healing. Indeed, perhaps one key lesson of this pandemic is that we are, and have always been, deeply connected to one another. This interconnection is not just emotional — it’s in the very air we breathe. Our health is bound up in the health of others, even people we have never and will never meet. These truths must propel better health policies, including the future of masks.
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Specifically, we must consider a less binary future of masks (either “all on” or “all off”) and adopt instead strong public health recommendations around mask-wearing during the peak flu and other viral illnesses season (December through February) that, like COVID-19, are driven by aerosolized transmission. Mask wearing should be encouraged and even incentivized for individuals entering crowded indoor public spaces such as airplanes, grocery stores, concert halls, and indoor stadiums during these peak viral months. We should encourage one another to wear masks when we are sick (and better yet, also provide equal sick pay so people can stay home without fear of losing their jobs) and have masks available at the doors of all public institutions.
Could Americans really ever adopt a different long-term attitude toward masks? While seemingly impossible in this age of great public health politicization and polarization, there are examples of cultural transformation around health in our country. Take seat belts as an example. Though the National Highway Traffic Safety Administration required seat belts in all American cars made after 1968, only 14 percent of the population routinely wore seat belts in the early 1980s. Like today’s masks, seat belts were seen as an infringement on individual rights. In 1989, Transportation Secretary Elizabeth Dole helped pass a rule that all cars would need to install airbags (an expensive proposition) unless two-thirds of states passed laws mandating seat belts. Car companies quickly began to lobby states for seat belt rules. The Highway Traffic Safety Administration estimates that seat belts now save 15,000 lives a year — a number below the number of lives masks could save by approximately 20,000.
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Nearly 200 years ago, German philosopher Georg Hegel penned, “We learn from history that we do not learn from history.” As we begin to write the last pages of what has been a devastating chapter in American history, let us finally learn from the lessons of 1918 and the last year in order to change the course of our future health.
Dr. Katherine Gergen Barnett is vice chair of Primary Care Innovation and transformation director in the Department of Family Medicine at Boston Medical Center, associate clinical professor at the Boston University School of Medicine, and a fellow at the Boston University Institute for Health Systems Innovation and Policy.
