Reston, USA - April 9, 2020: Social distancing sign at cashier check-out aisle inside Trader Joe's grocery shop store during coronavirus with woman employee in mask.

Passing the Buck: What the CDC Guidance on Masks Gets Wrong About Public Health

By Carmel Shachar

As Americans shed their masks in response to recent U.S. Centers for Disease Control and Prevention (CDC) guidance, the most vulnerable among us face an unfair choice: either to enforce public health hygiene or forgo being in public spaces entirely.

The new guidance, which states that fully vaccinated people can resume activities without wearing masks or socially distancing, is too nuanced for a country in which a significant percentage of adults continue to refuse vaccination and there are no mechanisms to enforce masking or social distancing for the unvaccinated.

Ultimately, this shift in policy unfairly burdens small businesses and individuals to be the guardians of public health, when it should be our community leaders responsible for enforcing public health norms.

Indeed, a significant number of state and private actors have applied the CDC’s recommendations too broadly by removing masking requirements in an effort to “get back to normal.” Many states, including Maryland, Virginia, North Carolina, Ohio, and Michigan responded to this change in guidance by quickly lifting mask mandates, even for indoor activities. And they are doing this before the data suggests that vaccination has gotten COVID-19 fully under control in their areas.

For example, the County Health Officer for Flathead City, Montana said that not enough people will get vaccinated to reach herd immunity in his area, and that the state may not be able to reach herd immunity either. Yet the Governor of Montana has signed an executive order prohibiting Montana businesses from requiring documentation of vaccination from their customers. And Montana does not have a state-wide mask mandate, and has a law that prevents the implementation of mask mandates at the county-level.

In many states, the lack of governmental leadership means that private businesses need to enforce public health precautions. Some bars in Philadelphia and clubs in North Carolina now require two key pieces of documentation to get in: your ID and your vaccination card. In my neighborhood of Cambridge, MA (where vaccination rates are sky high and even vaccinated people still tend to wear masks), many restaurants and coffee shops have signs asking customers to still mask up.

Enforcement fatigue, however, is very much a thing among restaurant and hospitality workers. They’ve taken a year of abuse from patrons for enforcing mask mandates with the full weight of the CDC and, often, their state governments behind them. Is it fair to ask someone whose pay depends on tips and customer service to enforce good public health hygiene and ask unmasked customers to show proof of vaccination or to mask up? On the other hand, is it fair to ask these workers to be exposed to a stream of unvaccinated, unmasked customers and clients? Even if the employees are vaccinated themselves, the vaccines are great, but not 100 percent effective.

We elect government leaders and appoint public health officials in part to promote good public policies. Shifting the responsibilities of public health leadership and enforcement to service workers is asking them to do work above their paygrade.

Further, allowing people to go unmasked and unvaccinated means that others endangered by this behavior cannot go about their daily lives. For example, parents of young children are venting online that they cannot bring their children to the grocery store or other public places now that mask mandates have been lifted, out of worry that the other customers may be ignoring the part of the CDC’s guidance that only lifts restrictions for the vaccinated. Cancer patients, those with organ transplants, and other immunocompromised individuals are also left to fend for themselves, because our public policies do not effectively compel mask or vaccine compliance.

So where does that leave us? Without mask mandates, or a way to verify who is truly vaccinated, likely through vaccine passports, we have virtually no tools to reflect the nuance of the CDC’s new guidance.

The Biden administration has been very reluctant to provide any leadership on vaccine passports. Likewise, most states are reluctant to require proof of vaccination, probably because it is politically unpopular.

Rochelle Walensky, Director of the CDC, tweeted “your health is in your hands” soon after the new guidance came out. Essentially, we are normalizing an “honor system” in which people are supposed to self-police their behavior, wearing masks if they are unvaccinated.

But as Paul Offit, Director of the Vaccine Education Center of Children’s Hospital of Philadelphia, recently told Philly Magazine “What about the past year tells you that adults are out there doing what they should be doing? We couldn’t even get a significant part of the population to wear masks. There’s still so much denialism. And we are still in a pandemic. So no, I don’t trust my neighbor to do the right thing.”

Dr. Offit is right to be skeptical. A recent poll of 2,200 U.S. adults found that 51 percent of unvaccinated adults were comfortable resuming their normal activities without a mask (for comparison, only 34 percent of vaccinated adults felt comfortable going maskless). Moreover, the U.S. is well under the threshold for herd immunity, and 13 percent of Americans are firm holdouts, reporting that they definitely will not get the vaccine. Of course, this is a national average, and we know that certain areas of the country have much, much higher rates of vaccine hesitancy than 13 percent.

Mandating vaccines is politically fraught. Requiring proof of vaccination to allow individuals to go maskless is also politically fraught. It is understandable that politicians and public health leaders at every level would be reluctant to push for vaccine mandates, vaccine passports, or maintaining mask mandates in perpetuity. But part of holding these positions means accepting the mantle of community leadership. As it is, we are devolving responsibility for public health hygiene and enforcement to people whose job description certainly does not include those activities. We are also failing those with heightened vulnerabilities. This abdication of responsibility is not fair to those left holding the bag.

Carmel Shachar

Carmel Shachar, JD, MPH, is the Executive Director of the Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics at Harvard Law School. She is responsible for oversight of the Center’s sponsored research portfolio, event programming, fellowships, student engagement, development, and a range of other projects and collaborations. She is Co-Lead of the Center’s Involvement with the Regulatory Foundations, Ethics, and Law Program of Harvard Catalyst | The Harvard Clinical and Translational Science Center.

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