Masking Dilemmas and Travel Options
We are asked the following questions regularly by medical colleagues, patients and their families:
1. “Where can we go where we don’t have to wear face masks?”
2. “Where can we go where we don’t need a PCR test, which can stay positive for 3 months when you have been healthy and not a health risk to anyone for 2 months or more?”
3. “Where can we go where we don’t have to quarantine or take tests after arrival?”
4. “Who accepts the AstraZeneca vaccine (most of the global population’s vaccine, excluding mainland China) now?”
5. “Where can we go where we can experience some normal to sustain our health?”
6. “Where can we go where we can experience some freedom to sustain our health?”
Vaccine data (currently):
• Oxford-AstraZeneca vaccine is used in 181 countries, Pfizer-BioNTech is used in 111 countries, Moderna is used in 64 countries, Johnson&Johnson is used in 38 countries. There are many other vaccines on the global market.
• As of July 2021, the AstraZeneca vaccine is recognised by the most countries (119) globally, followed by Pfizer (90).
• To date, AstraZeneca has released more than 1 billion vaccine dosages.
• To date, more or less 4.31 billion doses of vaccines have been given to the general public.
• More or less 15% of the global population is now fully vaccinated.
Medical and mental health colleagues, patients and their families are concerned about face masks for many reasons, these are the most common:
1. “People now started smoking again to avoid face masks, at least 50% of people I know.”
2. “My patients report increased drug use, prescription and non-prescription medication use and alcohol use to cope with face masks, which has been a firm pattern for the last year. People say they use near nothing or absolutely nothing on days they don’t have to wear face masks.”
3. “Many of my patients and even colleagues say face masks make them constantly anxious, agitated, irritated, often very angry, aggressive and many say very depressed and suicidal. This has devastating effects on health and on a society and especially a society’s children.” Patients report that it is “helpful to know others feel the same, that I am not alone, that there is nothing wrong with me for having these feelings”, which is why many of these statements are shared.
4. “Many of my patients are now so dependent on face masks, they even wear it when alone at home, with symptoms of OCD, phobias and depression. Mental health concerns will increase significantly in years to come.”
5. “Many people are handed face masks by others, even professionals in hospitals, with unwashed hands, touching both sides of uncovered masks, and no one seems to realise that face masks must be clean to reduce risk, otherwise it increases risk for infection, but masks are now a rabbit’s foot or symbol of care or safety, which unfortunately is far from accurate.”
6. “My patients and even colleagues report that their health has taken a turn for the worst only due to stress due to lack of freedom to leave home, travel, have a normal life, and most importantly, having to constantly wear face masks even though there is no good evidence and in many cases it makes no clinical sense, similar to PCR policies that make little clinical sense. The truth is many medical doctors don’t believe that all of this ‘abnormal’ is clinically indicated and many think it only causes harm.”
7. “Clinical evidence must be good, otherwise it can’t be called clinical evidence, all medical doctors agree with this, and it must mean something, and rights of liberty, capacity, competency, choice, autonomy, normalcy, must mean something, if we are to protect anyone. I hope the new normal means one thing; following good clinical evidence and medical leads with experience in medical crises.”
8. “There is a place where face masks might be helpful, but clinical evidence, context and clinical indications must be considered, it is also very important to consider that face masks, when mandatory for everyone indoors or outdoors and / or associated with threats, increase mental health risks and social risks (such as child abuse, domestic violence, drug abuse) for a very large part of the population, a larger part than high risk to covid” and “it is so crucial that people make decisions about masks for themselves, that they are not told what to do, this reduces risk on all fronts”.
9. “Look at the countries where face masks are ‘recommended’ or ‘encouraged’ in certain contexts, rather than ‘mandatory’ or ‘with threats’, it is very clear that a good outcome requires respect for the patient and clinical evidence.”
What Does The Evidence Say?
What Do International or National Health Organisations Say?
There is currently no good clinical evidence that supports the indiscriminate wearing of face masks for the general public in the community, indoors or outdoors.
Please see relevant statements from the WHO and ECDC regarding when face masks might be useful or helpful.
Please know that it is essential when engaging in a behaviour, such as face mask wearing, to engage in the behaviour safely (quality of behaviour), otherwise risk might increase markedly rather than decrease.
We have asked 50 individuals in more than one country, different age groups, cultural and educational backgrounds, what ‘safe face mask wearing’ means and most responded – “cover your nose and face”. Not one person responded that only clean hands must handle a face mask and that face masks need to remain in clean environments between use, which are essential. In many Asian countries face masks are purchased alongside, same purchase, face mask bags.
It is also important that the person makes the decisions regarding when the context requires a face mask, rather than officials. This is standard practice in Medicine. This falls under ‘quality of behaviour’. This is likely to reduce clinical risk, rather than increase clinical risk.
Recommendations regarding Face Masks by the WHO (World Health Organisation) and the ECDC (European Centre for Disease Prevention and Control):
“At present there is only limited and inconsistent scientific evidence to support the effectiveness of masking healthy people in the community to prevent infection with respiratory viruses, including SARS-CoV-2” World Health Organisation.
More details available at https://apps.who.int/iris/rest/bitstreams/1319378/retrieve.
Recommendations regarding face masks, World Health Organisation:
1. “Wear a mask IF you cannot maintain a physical distance from others”.
2. “IN AREAS WHERE THE VIRUS IS CIRCULATING, masks should be worn WHEN you are in CROWDED SETTINGS, WHERE YOU CAN’T BE AT LEAST 1 METRE FROM OTHERS, and in rooms with POOR OR UNKNOWN VENTILATION.”
3. “Individuals/people with higher risk of severe complications from COVID-19 (individuals > 60 years old and those with underlying conditions such as cardio-vascular disease or diabetes mellitus, chronic lung disease, cancer, cerebrovascular disease or immunosuppression) SHOULD WEAR medical masks WHEN physical distancing of AT LEAST 1 METRE CANNOT BE MAINTAINED.”
4. “Caregivers or those sharing living space with people with suspected or confirmed COVID-19, regardless of symptoms, should wear a medical mask WHEN IN THE SAME ROOM”.
Recommendations by the ECDC (European Centre for Disease Prevention and Control):
1. “IF YOU ARE INFECTED, the use of medical face masks (generally pale blue in colour and available from pharmacies) MAY reduce the risk of you infecting others.”
2. “CONSIDER using a face mask when visiting BUSY, ENCLOSED SPACES, such as grocery stores and shopping centres, or when using public transport, WHERE IT IS NOT POSSIBLE TO MAINTAIN A SOCIAL DISTANCE FROM OTHERS.”
3. “We strongly RECOMMEND the use of medical face masks for individuals with risk factors for severe COVID-19, for all people in airports, and for all passengers during flights.”
4. “Wear a face mask indoors and outdoor WHENEVER PHYSICAL DISTANCING with other people CANNOT be guaranteed”.
Many countries have different approaches:
Recommendations as published in newspapers in a country in Asia, February 2020, a country with experience and relative success in managing previous and current outbreaks of coronavirus:
1. “Do Not Wear a Mask” unless at higher risk: “Do Not Wear A Mask If You Are Well.”
2. “Who Needs To Wear A Mask? IF you have a Fever, Cough or Runny nose and IF you are Recovering from an Illness.”
It is our understanding that the CDC has recommended that masks should not be compulsory where 95% of the attendees have been vaccinated, this includes cruise ships.
Cruise Ships and Flights
It is our understanding that in some of Hong Kong’s Cathay Pacific flight departments, face masks are not mandatory in certain contexts.
Please know, as mentioned before, during the first 5 months of the outbreak masks were not compulsory during nearly any of our flights. Many airlines confirmed that they maintained good ventilation and adequate spacing or social distancing. It must be added that these flights were mostly in Asia and that core temperature and symptom screens were common and consistent practice, which markedly reduced risk. We have monitored statistics during the start of the outbreak. It is our opinion that this practice did not increase clinical risk.
HollandAmerica, Celebrity and Norwegian (NCL) cruise lines also offer cruises without mandatory face mask wearing policies in most contexts. Contexts where masks must be worn include disembarkation.
The WHO and the ECDC therefore still do not recommend indiscriminate mandatory face mask wearing as an initiative for the general public; it is clear that the WHO and ECDC specify specific contexts where this initiative can possibly reduce risk on balance, which cannot be ignored, generalised or misinterpreted.
These recommendations also make sense from a clinical point of view based on clinical training and clinical experience, along with research and statistics that risk is increased and harm is caused by these initiatives if not applied as clinically indicated.
Our Clinical Opinion and Recommendations:
Based on more or less 15 years of clinical medical training and more than 20 years of clinical medical experience in the NHS, further to critical review of the clinical evidence available relating to face mask wearing, we agree that there is currently no good clinical evidence supporting the routine and indiscriminate wearing of face masks by the general public in public settings and therefore we agree with the recommendations of the WHO and ECDC as above.
Please know that ‘critical review of clinical evidence’ is a specialist medical subject where medical doctors specialising in different specialist fields or departments undergo extensive training and then subsequent testing and examination in the field to appropriately evaluate clinical evidence.
We offer services in developing countries. We have extensive experience with systemic bio-psycho-social risk assessment and management; mental health, social risk as well as general health clinical presentations including serious medical problems and infectious diseases, along with implications relating to vaccines, nutrition and the immune system.
We are concerned about ‘blanket’ policies and mandatory statements relating to face masks where no clinical evidence supports these initiatives, such as in areas where there is no or little crowding and good ventilation. We are concerned when the focus is not on education and allowing the public with capacity to make decision regarding the wearing of face masks, to make these decisions for themselves; these decisions should be in the hands of individuals in the general public. It is our opinion that this is paramount to protect mental health, general health and reduce social risk and harm.
We are concerned about increased harm in terms of social risk, mental health risk and general health risk eg due to negligent wearing of masks or secondary to chronic anxiety, anger and depression.
We have shared these thoughts with relevant authorities, who mostly share our concerns.
1. Crowding can be and should be reduced, limited and avoided in most contexts. Crowding can lead to many general health, mental health and social risk concerns in any circumstance, not only in the context of a pandemic. Many countries have as cultural norm, a priority, to avoid crowding.
2. Ventilation can be and should be improved, increased and maintained at high standards. Poor ventilation can lead to many general health concerns, not only in the context of a pandemic. We have raised these concerns regarding waiting rooms with GP surgeries for the last 20 years.
3. Evidence-based protective factors for mental health, general health and social risk should be prioritised. We have discussed these at length.
We have been asked to share thoughts regarding Vaccine Passports and Vaccines for Children:
It is our opinion that the general public should be educated regarding potential benefits and risks of vaccines, and then be asked to make individual, educated and weighed decisions, as with any health or medical question or decision. Capacity and Gillick competence are relevant, as with all medical decisions.
The general public, professionals along with medical directors and CEOs have the responsibility to make decisions within the boundaries of the law to protect and to serve. Relevant laws prevent deprivation of liberty for good reasons relating to general health, general development, mental health, social risk and well-being. The definition of ‘state of emergency’ and relevant implications relating to deprivation of liberty, autonomy and normalcy should be reviewed on a regular basis and communicated to the general public.
The relevant clinical picture, as mentioned previously, has to be considered. Many viral infections or outbreaks pose a very high risk to nearly 100% of the population. We have discussed the risks relating to this outbreak.
Most medical doctors, many professionals and emergency staff agree to accept the vaccine, because they work with individuals at high risk for severe covid (5-20% of the global population).
Considering that most of these vaccines currently only have emergency approval status, it is our opinion that these vaccines should not be recommended or mandatory for children (and possibly young people) at this stage. Neurodevelopment is not ‘completed’ at age 18, some indicate that an age of 35 is more accurate. Doctors usually explain and help patients to weigh immediate, short term and longer term (over several years or decades) risks and benefits when making decisions. First Do No Harm is a principle most medical doctors prescribe to with significant commitment.
Different protocols or policies are required for individuals at high risk for severe covid compared to those not at high risk for severe covid to protect both groups equally. It might be necessary to have two protocols for individuals with vaccines and without vaccines for a period of time, however, we do not believe that refusal of entry or deprivation of liberty should be relevant in these circumstances.
We have been asked by medical, mental health and legal colleagues who agree with these concerns and statements to share these views in this forum. Many of our colleagues have recently presented with serious health or mental health concerns, and clinical outcomes can be improved significantly with a focus on protective factors and good clinical evidence.
WE ALWAYS RECOMMEND THAT YOU FOLLOW THE LAWS, RULES, POLICIES OF YOUR LOCAL GOVERNMENT AND THE LOCAL GOVERNMENT WHERE YOU ARE VISITING.
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