children wearing masks.

Reconsidering Mask Mandates

By Carmel Shachar

The desire to get back to “normal” is an understandable one. And despite their prevalence for the last two years, masks don’t fit into most people’s concept of normal.

But removing mask requirements means rejecting yet another public health tool to control the pandemic and protect our health care system.

First, some context: most states haven’t had indoor mask mandates in place for many months. As of February 10th, only Washington, Oregon, California, New Mexico, Hawaii, Illinois, and Delaware had statewide indoor mask mandates. These remaining few states are now taking steps to end mask policies. Some states have narrower mask mandates that apply to schools, and are similarly moving to end such policies.

But the decision to end these mandates is not made in a vacuum. We should be thinking about what other public health initiatives and components should be in place before we lift these protections.

If we had higher vaccination rates, we could skip masks

One argument for getting rid of masks is that we’ve taken a deadly disease and made it milder through vaccinations.

While it is true that countries with high vaccination rates, like Denmark (81.2% of the population fully vaccinated) and Sweden (72.8%), have seen lower rates of hospitalization and death during the current wave than less-vaccinated peer nations, unmitigated spread of the omicron variant has led to very high case counts and death rates per million that are approaching the rate seen last winter.

And the United States is comparatively worse off, in part because of our relatively low vaccination rates. During the omicron wave, we continued to add significant numbers to our COVID death counts and overwhelmed our health care system in most areas of the country. Americans now die of COVID at double the rate of Britons and four times the rate of Germans. Katelyn Jetelina compiled some charts comparing the COVID-19 experience between the United States, Denmark, Portugal, and Sweden. Consistently, and especially during the omicron wave, the United States has more patients in the ICU and deaths, and lower rates of vaccination than our peer countries.

Why does this matter? Until we can decouple infection rates from hospitalizations, each COVID-19 wave runs the risk of overwhelming our health care system. Denmark, Sweden, and some other countries, arguably have achieved that goal. The United States, as demonstrated in the omicron wave, has not.

Easing protections like indoor masking should be reserved for countries who have done the public health equivalent of eating their vegetables, i.e., achieving high rates of vaccinations. And even in that context, the data makes a compelling argument for mask requirements during periods of surging cases.

Governors, public health officials, and other policymakers should be thinking of how to incentivize communities to hit vaccination targets before they remove other measures aimed at controlling the pandemic and preventing our hospitals from being overrun again. We’ve consistently failed to take bold action to raise our vaccination rates, but there is still time and opportunity to try to implement some initiatives.

What if we paired ending mask mandates with digital health passes or vaccine passports? Some countries, such as Israel, have successfully implemented these programs. In the U.S., individuals who are up-to-date on COVID-19 vaccinations (i.e., who have received three doses of an mRNA vaccine or one dose of the J&J vaccine and one dose of an mRNA vaccine) could receive such passes and then be permitted to access public places. These digital health passes would strongly incentivize people to get all of their shots, bringing us closer to the national vaccination rates of Denmark and Sweden. As an added advantage, if future vaccinations are necessary, these passes can be used as a tool to promote uptake.

Alternatively, what if we approached mask mandates as a spectrum rather than a binary? Instead of lifting these protections entirely, we could say that mask mandates remain in place but are only triggered when cases in a county rise above a certain threshold. We should be thinking creatively about how to achieve our public health goals, including using removal of mask mandates as an inducement to vaccination, rather than removing all precautions out of a desire to return to normal.

If we had a pediatric vaccine, we could skip masks

The last inconsistency with the new trend towards ending mask policies is that a significant percentage of our population is — by no choice of their own — still unable to get vaccinated, and will remain unvaccinated for many months. The Pfizer Emergency Use Authorization (EUA) submission for children under five is again delayed, likely until April. Children in this age group are often required to quarantine for the full ten days, instead of the five recommended for vaccinated adults, which is hugely disruptive to their education, social development, and families’ ability to work.

Removing mask requirements ignores the vulnerability of these families. It is one thing to take an unvaccinated toddler to a grocery store where all adults are masked. It is another thing to take that child to a store where no one is masked. This is especially problematic because children under two cannot mask, older children are not great at wearing masks, and there are no N95 masks approved by NIOSH for children. Further whittling away mask protection is therefore premature at this stage. To protect younger children, it makes more sense to pause this discussion until a pediatric COVID-19 vaccine is available and kids under the age of five have had sufficient time to develop an immune response.

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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