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It Doesn’t Matter if Masks Work
I’ve been trying to stay out of this. I really have. But just can’t help myself. I’ve read every possible opinion about preventing the spread of COVID using masks. Some people say they don’t work at all. Others say that they work extremely well. Others say they work, but they don’t work because you morons can’t use them correctly. And there are many other variations out there. I haven’t posted on this topic, partially because I don’t know what I’m talking about. I don’t really understand what just happened. So much of this makes no sense. But I can no longer restrain myself. Allow me to propose my own theory: Nearly all the theories I’ve read are wrong. All of them. Well, pretty much. In my view, at least.
The use of statistics in medicine is complex. There are lots and lots of variables, most of which are unknowable. Discerning the impact of a treatment from random chance can be tricky. We try to follow a wide range of studies, but they often don’t agree. But let me try to illustrate my point at first by moving away from masks, and talk briefly of heart disease. This will seem off-topic at first, but you’ll see where I’m going soon. And the doctors in the audience may catch me over-simplifying the data a bit. I’m just trying to explain a general concept here, so if you send me a personal message that involves p-values, I promise I won’t read it. And this post is covering some complex topics, so it will be longer than my usual post. If you can’t stand the idea of reading anything else about masks, I won’t blame you if you just keep scrolling.
Ok. Because heart attacks are often fatal, we spend a lot of time and effort trying to prevent them, rather than treating them after the fact. There are two types of prevention, in the cardiovascular world. There is primary prevention, in which we take people who have not had a heart attack, and we give them some form of treatment, in an effort to avoid their first heart attack. Then, there is secondary prevention, in which we take people who have had a heart attack, and we give them some sort of treatment, in an attempt to prevent subsequent heart attacks.
Let’s start with secondary prevention. If you take 1,000 people who have had had a heart attack, and you give them all statin drugs, will you prevent subsequent heart attacks? Yes. The data is simply overwhelming. Statins work extremely well in this environment, all the studies show pretty much the same thing, and there is no longer any debate on their effectiveness in treating heart patients. In fact, it has become unethical to do placebo trials on such patients, because it is so obvious that heart patients live longer when you give them statins, you just can’t deny half the people in the study a treatment that you know will prolong their life. You are not allowed to intentionally kill people while doing research. If you know a drug works you can’t deny it to half the people in the study. So, yes, statins work extremely well when given to people who have already had a heart attack.
Ok. What about primary prevention? Well, in primary prevention studies, the data on statins is much more complex. Some studies show reasonable benefit, others show small benefits, and some show little benefit at all. While secondary prevention studies look very similar to one another, primary prevention studies are all over the map.
This seems odd, doesn’t it? You’re using the same drug (statins) to treat the same disease (heart attacks), but you’re getting different results in primary prevention vs secondary prevention studies. They should show the same thing, right?
Can you figure out why there are such striking differences between the two types of studies? I’ve given hundreds of speeches to various doctors’ groups across the country on this topic, and I would be embarrassed to tell you how many physicians in my audiences can’t figure out the difference. Do you know what it is?
Since the treatment is the same, and the disease is the same, the difference must be the patients, right?
Think of it like this. In a secondary prevention study, all of the patients have heart disease, and you know it. They have had a heart attack. You don’t need a cholesterol panel or a blood pressure check to figure out if they are at risk for heart disease. You know they have heart disease.
Now, suppose that statins reduced risk of heart attack by 50%, just for simple math. If all of the patients in the treatment group have active heart disease, you might hope that your prevention numbers might get as high as 50%, right? It won’t be that high, of course, because not everyone who has a heart attack has a second heart attack. But many do. So your reduction of risk and heart attacks looks pretty good in that population because they all have heart disease.
Ok, so now think of a primary prevention study. You’re going to take 1,000 people who have high cholesterol, and you’re going to treat them all with a statin, and you’re going to see how many heart attacks you can prevent. Suppose you’re using the same statin, with the same 50% reduction in heart attacks. So will you be able to reduce heart attacks in that group by 50%?
No, because not everyone with high cholesterol will have a heart attack. OK, so how many people with high cholesterol will have a heart attack? It’s hard to say because that would depend on many other variables. But it’s probably not half (depending on how high their cholesterol is), and it may not be 25%. Around 75% of heart attacks occur in people with normal cholesterol.
So treating people based on one risk factor (say, high cholesterol), will result in you treating a lot of people who will never have heart disease. Whether you treat them or not.
Suppose you had a crystal ball, and you picked out 1,000 people with high cholesterol that you somehow knew would never have a heart attack. Your crystal ball said they were all going to die of pneumonias or car crashes or something. Ok, so now you give all 1,000 of them a statin. What will your success rate be? Zero percent. Because none of them were going to have a heart attack to begin with.
So let’s suppose, that in your high cholesterol study, 25% of the people in your study group will eventually have a heart attack. And suppose statins reduced the risk of heart attacks by half. In that case, the very best your statin could do would be to reduce the risk of heart attack by 12.5%. So you’re only getting a 12.5% reduction in heart attacks, even though the risk reduction from our hypothetical statin is 50%.
But it will probably be less than 12.5% because not everyone will take the medicine properly, some of them will take up smoking, some of them will get older during the study and develop diabetes, and so on. So in your high cholesterol study, a drug with risk reduction numbers of 50% may work less than 10% of the time.
Why? Because a lot of the people that you’re treating didn’t have heart disease to begin with. Whereas in the secondary prevention study, they all had heart disease.
In my speeches, I tell my doctors that if they’re using statins for primary prevention, they had better know what they’re doing with diagnostics, or else whatever treatment they use won’t work. No matter how effective it is. And if all they’re doing is giving statins to people with high cholesterol, well, good luck.
Ok. So after all that, let’s talk about masks.
Do masks prevent the spread of COVID-19? Maybe. Some studies have shown no benefit at all, but some have shown small risk reductions. Not 50%. Maybe 10%? If you choose your data carefully and squint a bit when you read the stats section, maybe 20%? Maybe. But probably less than that. And again, according to several studies, it’s close to zero percent. So the real benefit of masks, under ideal circumstances, is difficult to say for sure.
My point, though, is that it really doesn’t matter how effective masks actually are.
Let’s say for example that you went to a grocery store last year, at the height of the pandemic. Suppose there were 100 people in that grocery store. And suppose all 100 people, including you, are wearing masks. Ok.
How many of those people have active COVID-19 infections at that moment? Half? Of course not. All of these people are healthy enough to go shopping. 25%? Heavens no. Let’s just say for the sake of argument that there are five of those 100 people who have active COVID-19 and don’t know it. If they’re feverish and coughing their heads off, you’ll probably give them some space anyway. So I’m talking about asymptomatic, or nearly asymptomatic, but active, COVID-19 infection. Again, let’s say there are five of those walking around your grocery store.
So your risk of becoming infected with COVID-19 is 5%, then, right? Well, no. How many of those 100 people are you likely to have extended close contact with?
Remember that the vast majority of the infections we tracked occurred at home, or other places where people are in very close contact, in very small spaces, with so-so air circulation, for extended periods of time. Transmission of COVID-19 in public places is rare, whether you wear a mask or not.
So you could argue that we should be wearing masks at home, but not once you leave your house. I don’t think that would help much, either, but I suspect it would work better than wearing masks in public. That would be an interesting study. And good luck enforcing compliance in that study. Talk about hypothetical benefits…
Anyway. So those five people wandering around the grocery store do not give you a 5% risk of catching COVID. Let’s just guess your risk of catching COVID-19 in that store is 1%, just for the sake of argument. I think that’s really high. Some of you may think it’s a bit low. But whatever.
Remember that on that floating petri dish – The Diamond Princess – over 80% of the elderly passengers did not get COVID-19. And they were up to their necks in it for weeks. And they were all old. They weren’t middle-aged healthy people just wandering around a grocery store for 20 minutes.
But again, the exact number doesn’t matter much. Pick a number that makes you happy. But regardless, it’s low.
Ok.
Now, let’s suppose that masks can reduce the risk of COVID-19 transmission by 20% when used properly. Firstly, I think that’s extremely optimistic, based on the studies we have. And secondly, I would guess that the number of masks in that grocery store being used properly is vanishingly small. But let’s suppose that the studies are wrong, and the grocery shoppers are unusually vigilant with sterile techniques, and the masks in this grocery store actually do reduce the risk of COVID-19 transmission by 20%. Right.
So if your risk of getting COVID-19 in that store was 1%, and you reduce that by 20%, now your risk of getting COVID-19 is 0.8%.
So you reduced your risk of COVID-19 by 2 people out of 1,000. That’s not nothing. But it’s close. And again, I think that’s extremely optimistic.
Why are masks so ineffective, even if we presume that they are effective? Because almost everybody that is wearing them does not have COVID-19. So in those people, there is no chance that they could provide any benefit, regardless of how effective they are.
It’s like giving statins to people who have high cholesterol but don’t have heart disease.
Ok, look. The stats geeks out there are going to notice some shortcuts I took with my math. I used simple numbers simply to make a point. This isn’t meant to be a precise statistical analysis. And others may argue that it’s no big deal to wear a mask. With no real downside, why not, right? And the fans of masks may be plugging more optimistic numbers into my ham-fisted formulas above. But it won’t matter much. Maybe a little. Not much.
Also, just suppose that a new study came out tomorrow that showed that masks reduced the risk of COVID-19 by 50% or something, in that particular study, when you use a certain mask, with a certain sealant, for a certain period of time, or whatever.
Ok, that’s swell. But I don’t care.
Not until somebody can show me some very real benefit in an actual population of actual people leading their actual lives. If masks work only when used properly, but no one uses them properly, then that doesn’t help.
The research on statins was very exciting early on, but their use didn’t really take off until doctors started to see heart attack rates drop significantly in the population at large. That meant that they didn’t just work under the ideal circumstances of a controlled study – they worked in the real world, too. That’s when we really started using a lot of statins.
Also, you can reasonably argue that masks were a good idea, because they got people to leave their houses, and they got the economy going again. That may be true, but that’s not my point.
And I emphasize that I’m speaking of normal people wearing masks in public. I’m not discussing the use of masks or other protective equipment in medical settings. That’s not my point, either.
So what is my point?
If you feel safer wearing a mask, by all means, be my guest. I don’t think they’re entirely benign, but I agree that the risk from wearing masks appears to be small. So whatever.
But if you’re curious as to how much protection that mask is actually providing you, color me skeptical. I obviously don’t know the real benefit of wearing masks, but I strongly suspect that it is extremely, extremely small. A suspicion that has been borne out by population studies around the world.
I openly acknowledge that I don’t know the precise risk reduction provided by masks used in public settings. But I don’t think anyone else does, either. I’m just saying that whatever that number is, I suspect it’s really low.
And I think it’s important that we think this through because this is going to come up again. Probably soon. And next time, we should have a plan.
A plan with some real-world data behind it.
Our response to this virus has been a fiasco. I hope we learn from it.
I suspect we won’t.
Published in General
Any number that has been run through the American media is to be disbelieved until verified by a real data source.
Very nice, Doc, and I’m glad you weighed in.
And by “the stats geeks out there,” we all know you mean Jerry.
Thank you! Thank you, thank you!
I honestly don’t understand why more people can’t grasp these concepts. Although few people can elucidate as you have here in this post so well.
Not to say it’s simple exactly, but it’s not hard is it? Am I that smart? I don’t think so, but…maybe. That makes me sad if it’s true.
It’s like this guy:
Doc, when this all started our firefighters really, really didn’t want to wear masks. I didn’t either, so I left it up to them to decide. We spend maybe 6 hours per month training in close quarters, and when we make calls (the frequency varies a lot) we are on top of each other for anything from 1/2 hour to all day or night. We didn’t have a single infection, and more than once we were in a home doing medical treatment where we later found out the patient was infected. We always glove up but only once (for a full arrest) did we all mask up for the entire call. I do a lot of CPR and BLS classes at our firehouse; students would show up masked and when I told them that masks weren’t required to a person they took them off and said “good”.
Local and national news media screamed when Governor Abbott dropped the mask mandate – our braying jackass POTUS even called us “Neanderthals”. And what happened? Deaths and infection rates plummeted. As you said, we will never be able to prove what happened. Nonetheless, many Americans have shown that they have almost an addiction to fear, as if it’s some sort of vicarious thrill. Rampaging Karens have appeared to feel empowered to harass anyone that doesn’t submit to their will. I still see 20 somethings walking around masked, and that worries me more than anything else.
This is a very good summary of the new research by Dr. Marc Siegel of Fox News.
https://video.foxnews.com/v/6256423959001#sp=show-clips
The only thing they were good for was when you were near somebody for a limited time indoors.
They didn’t do a damn thing at the societal level. Nobody’s risk was lowered by this policy. The medical system didn’t conserve any resources from it.
The Danish study said it was 14% efficacy if you measured it like a vaccine.
What month should they have dropped the comprehensive, top down mask policy? I say August 2020.
How in the hell can the pro-mask camp explain how the virus blue through every single mask mandate?
Which it’s not.
Careful with taking math like that and extrapolating it across a completely different population.
Which I know is not what you, personally, were doing. But I’ve seen others try to make that point.
Right. I’m just repeating something I heard. I thought the whole study was dumb because it wasn’t about the coefficient of spread. People were so worked up about it.
I am fairly certain that this pandemic has done more to cause widespread PTSD than anything else in recent memory. The kids and 20-something’s take the news as NEWS, as if it’s actual, literal facts (assuming they like the lean of the network/website).
And frankly, many of them have associated masklessness with “Right Wing Nutjobs” and “Anti-Science Idiots”. They wouldn’t take off a mask and dare associate themselves with those people.
I’m glad that providers of medical services do ok even with doctors most of whose thinking ability is so limited, after so many years of education and so many stages of filtering out people who can’t think, that they don’t already know what you tried to teach them. I’m glad you tried to teach them because you surely must have caused a few light bulbs to turn on, and those few must have successfully taught others to think, too.
And probably OCD as well.
If the government mandated the carrying of rabbit feet, how many people would keep carrying them after the requirement was lifted? More than zero.
The problem is that we knew early on that SARS-COVID-19 was particularly bad for persons with compromised health, especially the elderly. However, we never built a strategy to assist and educate those closest to the vulnerable to circle the wagons there. Masks would have been a logical component of localized intensive protection strategies.
We were instead ordered to pretend that children were at risk, that healthy young adults should curtail normal life in a spectacularly warped risk-benefit calculus. Then we had to pretend that magical permutations of 6 foot distancing, utterly gratuitous surface cleansing and asinine pseudo-fine tuning of restaurant capacity percentages were all actually effective measures and that the pandemic would sweep all before it if we let up. COVID cases rose and fell in almost identical regional patterns whatever the different strategies deployed. Nothing had ANY measurable effect. And despite this obvious pattern behavior (consistent with all respiratory pandemics even if more contagious) we got unscientific crap about “impending doom” from “experts” even as the curve was on the downswing.
Masks were the most visible symbol of an absurd regimen that revealed the terrifying truth that a huge percentage of Americans really do want to surrender personal autonomy to bureaucratized rule done under the rubric of vague and largely false allusions to “science” and civic-mindedness.
The fervent desire by so many to deify Fauci, a prevaricating, self-promoting, utterly ridiculous man is scary. The American response to COVID-19 was an own goal on a gargantuan scale emerging from a serious defect in the character of our society and the caliber of those we choose to lead us.
Excellent post, thank you!
There was one aspect of masks that I thought you were going to say in conclusion but didn’t: Mask mandates were unnecessary (or whatever word you felt appropriate).
Thank you for articulating what I had inferred from many more less clear articles.
And masking is about virtue signaling and maintaining fear. Because many apparently like the fear.
But you or Rodin wrote about that already.
How can anyone be that credulous? I have observed what you are saying but I do not understand the widespread nature of such a faith mentality.
Because it’s simple. And most people simplify things outside their focus area. It’s probably what is behind the Gelman amnesia effect. Faith and religion, as a cultural institution, helps with the simplification. Currently, our cultural religious institution is faith in government with a patina of Christian ritual.
I wrote once before that our fellow citizens were skating eerily close to believing our rulers were capable of god-like action. It was mostly satire, but there’s some truth there. Governments ruling as gods simplifies their jobs in controlling the people. I suppose it’s shocking given the enlightenment, but we’ve been witnessing how destroyed the scientific institutions have become and how devoid of reason the electorate was over the last election cycle.
Thanks. I suspected the whole thing was managed for its impact on the political and economic power of specific groups.
They’ll do away with that patina, by and by. Getting people to accept the government as godlike would be a whole lot easier then. That plus a little light genetic engineering to make compliance more pleasurable …
The religious impulse is so utterly imbued in humanity I quite doubt we will be able to finesse it anytime soon.
@Stina Can a society have a persistent faith if the government doesn’t support the faith? We seem to be abandoning the good and useful religion of Christianity for Wokism, vulgar paganism and an even more vulgar worship of government power. I’m not sure why.
The biggest problem with masks is they were externally mandated. Individuals were conscripted to wear them.
Only good news, the mandates proved the commonsense point: masks don’t work in any broad or significant way.
It’s broken record time!
I highly recommend the book How To Lie With Statistics by Darrell Huff. While some of the examples are dated (it uses 1954 dollars), the various methods by which statistics can be presented are still relevant today. Also relevant is the chapter on polling, particularly “scientific” polling . . .
How to Lie with Statistics by Darrell Huff
I don’t think it matters what the government does on the subject, except insomuch they prevent the active works of people of faith.
Government persecution explodes the growth of the very bold and courageous believers while theocracy breeds corruption and anemic faith that rests on cultural artifacts.
So I think the issue with western faith resides squarely with those charged with the keeping of the deposit of faith – believers and the religious leaders they elevate – rather than specifically with the government. Previous generations failed in passing it down and preserving the institutions they built or inherited connected to their faith – like the university system, education, and healthcare.
It is a good book; worth a read. If for no other reason, it will inoculate you against believing the next article that states that “Studies have shown …” when it is in fact very unlikely the studies in question have shown anything significant.
Makes sense. The American government has been pretty darn neutral with religion and we have had flourishing religion up until recently. So… why have the faithful so failed to maintain their faith?
Henry, this is my answer to your question.
I reject your premise.
Every government is founded on a religion; none can ever be neutral about religion. What is happening in America is that the people are exchanging one religion, based on worship of God, to another, based on worship of Man.
The faithful in the old religion of America who have failed to remain faithful did so for the same reason that man has done so since the first Man. Their children aren’t faithful because they were not brought up in the way. They inherited faithlessness.
What do you mean every government is founded in religion? America was founded in no specific religion but it was deeply inspired by Christianity that emphasizes natural rights.
I get that children brought up in faithlessness aren’t faithful but when and why did the faithful stop teaching the faith? According to Roger Kimball, it was the 1960s.
My generations’s parents were victims of reason over tradition. They, as a whole rather than a rebellious few, rejected the previous generations and generated principle for doing so rather than simply being young people doing what young people do.
Overwhelmingly, their approach to parenting was to “give options.” They were religious neutral and so they embraced the vacuum in their children’s lives. So the kids grew up with no foundation for why faith is important and treating it like an Ice Cream Sundae Social where you can pick your toppings to taste and preference.
There was no anchored tradition.
And in institutions that relied on tradition in a neutral fashion, they were forced into full on nothingness (the vacuum) through perversions of separation of church and state. Still, even so far gone as we are, our libertarian “conservative” thought leaders can not devise a constitutional argument for why even local commons can not hold onto faith centric traditions and mores. So we allowed our constitution to destroy the institutions built in faith that, through tradition and longevity, became owned in the community commons. And we have nothing to support a common faith institution. It must all be private.
It was founded in Christianity and because of the many flavors of Christianity, it rejected being an arbiter of which one was truly “right”. It would not be used by Catholics or Protestants to wage war on heretics. Ergo, separation of church and state.
And due to that, it adopted (Christian) faith neutral language in public statements of faith.
But it was explicitly founded with an assumption of Christian influenced philosophy and traditions to inform its own constitution and Bill of Rights, that being natural rights imbued by the creator. With no creator, what are natural rights? Can the philosophy remain deconstructed and the reconstructed without the Christian God, understood through Millenia of Christian theological tradition?