• M74 Editorial Team

Unmasking the Global Mask Debate

Updated: Mar 26

By Dr. Filipa Madalena Teixeira, M.D.

Over the past couple of months, several countries in Europe have banned the use of cloth masks in public places, and mandated the use of medical-grade ones instead. Currently, additional governments worldwide are weighing whether to do the same. Why?

In order to understand the rationale behind these decisions, you should be aware of the types of masks that exist in the fight against COVID-19. There are 3 main types of masks, recognized by the United States (US) Centers for Disease Control and Prevention (CDC):

1. Cloth (homemade and factory-made), 2. Surgical/clinical, 3. KN95/N95/FFP2

Since cloth masks are neither standardized nor well-regulated, their overall efficacy is hard to gauge, as they can be made using any number of methods and materials. Having said that, studies have shown that the efficacy of cloth masks varies between 26% and 80%, depending on how many layers are present and which fabrics they are composed of. Ideally, a cloth mask should have 3 layers of protection: an inside layer made of an absorbent fabric (such as cotton), an outside layer made of a water-resistant fiber (like polyester), and an in-between layer where you can insert a filter. Minimum Efficiency Reporting Values (MERVs) on a scale of 1 to 20 exist for most filters and related materials. Stated simply, the higher the MERV, the better the filter. Another way of achieving greater protection is to wear a surgical mask beneath your cloth one, since recent research from the CDC found that doing so can diminish transmission rates by up to 96.5%, as opposed to just wearing an “average” cloth mask on its own. Cloth masks with exhalation valves or vents are not recommended by the CDC, as they may allow droplets to enter or escape.

Surgical/clinical masks are made of 3 layers of polypropylene plastic, and offer a higher degree of protection than your “average” cloth mask. They are designed to be single-use, and should not be worn for more than 4 to 5 hours.

The KN95/N95/FFP2, which are also made of polypropylene plastic, are by far the most effective masks you can wear, filtering at least 95% of airborne particles. As a result, they are the most sought-after masks by healthcare professionals. KN95/N95/FFP2s are also designed to be single-use only, although the duration for which they can be worn varies.

Following the emergence of new and more infectious variants of COVID-19 (such as the ones originating in the United Kingdom, South Africa, and Brazil), France and Germany mandated the wearing of surgical masks in all public places. Meanwhile, Austria went a step further by requiring FFP2 masks to be worn in most shops and on public transportation. It should be noted that these 3 countries—and any others that have enacted similar policies, or are considering doing so—already have “mask mandates” in place, meaning that people are legally obligated to use some form of facial covering in public.

Austria’s decision is not without drawbacks. For starters, FFP2 masks are significantly more expensive to make, at up to €10 per unit, as opposed to surgical masks that cost under €1 per unit (often as low as 20 cents) to produce. The result is higher procurement costs, which ultimately get passed on to the end users. Another concern is the competition that may ensue between healthcare systems and the general public, in terms of acquiring FFP2s. If the former are deprived of these masks, then the latter will ultimately suffer—seeing as there may not be enough able-bodied healthcare workers to care for them if they become ill.

The sidelining of cloth masks also has environmental consequences. Masks of surgical quality or above are not reusable, while cloth ones are. As noted by the Korea Research Institute of Chemical Technology (among other institutions), plastic surgical and N95 masks are quite difficult and costly to recycle, so they either need to be incinerated or sent to suitable landfills. Many of these masks do not even enter the waste management cycle, due to rampant littering. For instance, every day, I see dozens of disposable masks scattered across the sidewalks and streets of my community. Madeira (where I live) is an island, and it often gets windy here. So, inevitably, many of these improperly-discarded masks find their way into the Atlantic Ocean—which is already grappling with alarming levels of plastic pollution. A study from last year by the United Kingdom’s National Oceanography Centre found that there are “12 to 21 million tonnes of tiny plastic fragments floating in the Atlantic Ocean.” To put these numbers in perspective, the Centre says that 21 million tonnes of plastic is “enough to fully load almost 1,000 container ships.”

If scientists can devise a way to make surgical and N95 masks—as well as medical gloves and other personal protective equipment (PPE)—using biodegradable materials, rather than plastic, without reducing their effectiveness, then that would be the ideal solution. However, such innovations are likely far-off, so focusing on how to recycle the plastic masks currently in circulation makes the most sense. At least one firm, Plaxtil in France, has already figured out a way to do so by using ultraviolet (UV) light. In the first half of last year, Plaxtil “recycled more than 50,000 masks, producing between 2,000 and 3,000 recycled PPE products.” Seeing as France has ordered over 2 billion masks, 50,000 represents a drop in the bucket. Until companies like Plaxtil sufficiently scale their operations, the best thing we can do is properly dispose of our surgical and N95 masks, while educating others about why they should do the same.

In addition to the environmental implications of banning cloth masks, doing so further jeopardizes already vulnerable industries that have come to rely on cloth-mask-making over the past year. The decline in global retail spending due to the pandemic has hit the clothing and textile sectors particularly hard. For instance, here in Portugal, lockdowns and restrictions have kept away the tourists who comprise a sizable share of our country’s retail spending, as well as reduced Portuguese exports across the board. According to the ATP (Associação Têxtil e Vestuário de Portugal), the clothing and textile industries in Portugal are directly responsible for more than 35,000 jobs. Last year, Portuguese clothing and textile exports dropped by 11%, and would have plummeted by 15% or more if factories had not switched to making PPE—namely, cloth masks. Currently, there are between 15,000 to 20,000 Portuguese jobs relating to cloth-mask production. According to Filipe Prata, whose Porto-based clothing company, Lagofra, pivoted from making apparel to masks last year, “thousands of people” at his factories could lose their jobs if Portugal (which represents 95% of his client base) prohibits cloth masks. Lagofra is already in a vulnerable position, seeing as Germany was the company’s largest foreign market for cloth masks until the ban was announced there in January.

Meanwhile, in certain countries, the debate is not about the types of masks we wear, but about whether we should be wearing them in the first place. Donald Trump of the US, Jair Bolsonaro of Brazil, and John Magufuli of Tanzania are arguably the world’s most prominent “anti-maskers.” All 3 men rarely wear masks in public, and are known for their large maskless gatherings. Presidents Trump and Bolsonaro both contracted COVID-19, while President Magufuli possibly died of it (although official reports claim that he succumbed to complications from chronic atrial fibrillation).

Masks, like vaccines, are not a matter of politics. They are a matter of health. Regardless of what type of mask mandate exists where you are, or whether one exists at all, the bottom line is you should always use some form of facial covering in public. The faster we can all get on the same page about basic things like mask wearing, the better we can focus on the genuine challenges posed by this pandemic.

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Dr. Filipa Madalena Teixeira, M.D. is a Family Medicine resident at the Câmara de Lobos Health Center in Madeira, Portugal. She is a graduate of the NOVA Medical School in Lisbon, Portugal. Her research interests include Psychiatry and Public Health.

The views expressed above are those of the author and do not reflect the official position of the M74 Group, which remains neutral on all matters. Publishers assume no liability for content.