Jordan: Hey, so you’ll never guess who’s now okay with wearing masks.
Clip- Trump: I think masks are good. I would wear– if I were in a group of people and I was close?
Clip- Interviewer: You would wear one?
Clip- Trump: Oh, I would. Oh, I have. I mean, people have seen me wearing one.
Jordan: After months of refusing to recommend it and refusing to wear it, as COVID-19 cases spiked to record highs in the United States, the president now says masks are okay. You can wear one. The problem is is it’s too late for people like this.
Clip- Aubrey Huff: I posted a tweet yesterday about no longer willing to comply for wearing a mask inside a grocery store. Now, if you want to wear a mask and live in fear, the rest of your life, it’s certainly your prerogative, but the vast majority of well adjusted sane, common sense people that aren’t sheep that can reason for themselves agree with me.
Jordan: That is Aubrey Huff. He’s a former professional baseball player and he’s not alone in those feelings. He’s just very public. This is a real sentiment in America right now. And Canada isn’t immune to it either. There is a reason cities across our country are now passing mandatory mask policies. Not enough people are voluntarily wearing them. Is that the politicians fault? Sure, partly. Messaging on this was handled badly. Is it our fault? I mean, those of us who aren’t wearing masks, yes. But we’re being asked here to radically change our everyday behaviour. And that just isn’t something we do very easily. And it doesn’t happen by telling us that we’re selfish, that we’re mask-holes, that we’re killing grandma. Even if that’s true, we need proper messaging on masks, encouraging messaging, if we want everyone to start wearing them. So what does that kind of message look like? What works? Well, we actually have an example. I’m Jordan Heath-Rawlings. And this is The Big Story. Dr. Julia Marcus is an epidemiologist and assistant professor at Harvard Medical School. She’s also been writing about COVID-19 for the Atlantic. Hello, Dr. Marcus.
Dr. Julia: Hi, thanks for having me today.
Jordan: Oh, you’re very welcome. My first question, I guess, is just, you’re talking to us from Massachusetts. How are you guys doing down there?
Dr. Julia: We in terms of the pandemic are doing pretty well. We were hit hard early on. And fortunately right now we are in a pretty good position, but of course we’re also slowly reopening. So we’ll have to keep an eye on how things play out over the next few weeks.
Jordan: And in the rest of the country?
Dr. Julia: Well, it’s not looking great across the country. Like Massachusetts, other places that were hit hard early on like New York are doing fairly well at this point. But there are some States that reopened very quickly that hadn’t had much of an initial wave of infections and are now seeing a huge surge. And there’s a lot of concern about healthcare capacity and how things are going to go in the next few weeks. So, things are not looking too good here right now.
Jordan: And today we’re going to talk about one of the things that might help. For context, you should know that we’re talking to you from Toronto where next week mandatory masking will kick in, in all enclosed public spaces. Which is something that has been done in some places in the United States, but not very many, if I’m correct.
Dr. Julia: Yeah, it’s been kind of a mixed bag and it’s been left up to states and even cities to make individual decisions. So it looks pretty different across the country.
Jordan: Well, why don’t we start, if you can, maybe give me the broad strokes on what we know about how wearing masks impacts COVID transmission. Do we have definitive studies?
Dr. Julia: Well, there’s a body of evidence that comes from, not just COVID, but other respiratory infections. And then we have some evidence from COVID itself. And we have evidence in different settings, health care settings, some evidence in community settings, and varying levels of evidence for cloth masks, N95 surgical masks, but taken together what’s important is that we’ve learned that people can transmit the virus when they’re asymptomatic. So the recommendation was always that anybody who is experiencing symptoms should wear a mask to protect the people around them. And then it became more apparent over time that asymptomatic transmission was contributing to the pandemic. And then it became much more of an important prevention strategy to have people who feel healthy wearing masks to protect others when they may not realize that they’re infected.
Jordan: And how much compliance, on a general level, are we seeing with that? Especially in the US, do you have numbers?
Dr. Julia: There have been some surveys done, and it’s a bit hard to tell because the questions are somewhat vague. Like, do you always wear a mask when you’re out of the house? Do you sometimes? Do you– you know, and it’s hard to know how to interpret that, but it does seem like most people are on board with wearing masks in public, but not all. So I don’t think the people who are ideologically opposed and actively resisting and literally going to protests about mask mandates, I don’t think that they are a substantial proportion of the population, but they do exist. I think there’s probably a broader, you know, a larger proportion of people who generally intend to wear masks and it doesn’t always happen. And then there’s a substantial proportion that really are adhering quite well to masks. And so, I think what we want to try to do is increase that adherence as much as we can across the board.
Jordan: Well, that’s why we’re going to talk about how masks are messaged, which is something even our public health officials up here admit they’ve struggled with. Do we know, right before we start, who are those people who are actively resisting wearing a mask or who just refuse, and why they do it?
Dr. Julia: Well, I can’t speak to what’s going on in Toronto, but it does seem in the US like masks have become quite politicized. So many of the people who are openly refusing to wear them are people who are more on the conservative end of the political spectrum. And do seem to be more likely to be men than women. And that may be driven to some extent by, up until literally yesterday, the president refusing to wear a mask and actively going against public health guidelines. And of course, that is going to trickle down from the top.
Jordan: Is this really all about the example set by politicians and Trump and people like him? Or is there something broader going on with regards to why people don’t wear a mask? Or why they don’t listen to advice to wear it?
Dr. Julia: Well, just thinking bigger picture, any new public health intervention faces some resistance. And, you know, there’s always, even if we think about something like seatbelts that are not particularly politicized, and you know, not especially uncomfortable, I mean, even seatbelts there was resistance. And, we always see this. But I think it’s unusual to have a sitting president flout public health guidelines. And I think that does have an impact and it does make it harder for public health messaging to do its job.
Jordan: What has public health messaging been like? What kind of tacts have they taken? And if you have examples, that’d be great.
Dr. Julia: Well, thinking back to the beginning of the messaging around masks, it really has been a bit of a mess. And I think that’s probably contributed to some extent to some of the resistance we’re seeing now. At the beginning of the pandemic can not only were public health officials saying that masks were not effective for reducing transmission, they were actually, in some cases saying that masks could do more harm than good. For example, by making people touch their faces more, by making them become lax about other prevention strategies like social distancing. And there wasn’t really any evidence to support those statements. And once they were made, it became even more stark when there was, you know, a 180 in messaging to, you know, now masks have become a really important prevention tool and we all need to get on board. I think there now is some frustration in the public about that change in messaging. So I think there’s now some efforts to recover. But in terms of the messaging that we’re seeing now, I think some of it is quite moralistic around, you know, you’re selfish if you don’t wear a mask, it’s equivalent to drunk driving and putting the people around you at risk, and if you had any sense of responsibility, personal responsibility, you would do this. And then there’s messaging that I think is a bit more attuned to what the barriers are for people. So I’ll point you to an example from the governors of California, who put out a video that tried to address some of the concerns around masks being an infringement on civil liberties, around masks feeling for some people like they’re a sign of weakness, and about actually ways that we can frame them as a ticket to freedom and a sign of strength. And I think that that kind of messaging, that really tries to address what the concerns are, as opposed to more paternalistic messaging, will ultimately be more effective.
Jordan: What kinds of responses does the paternalistic messaging tend to provoke? Not in everybody, obviously, but in some people, because we’ve seen, in your piece, you mentioned, and I saw the video, a former major league baseball player who, you know, was essentially rebelling against everybody who was telling him he had to.
Dr. Julia: Yeah, I think that that kind of messaging that relies on shaming and tries to shame people into changing their health behaviors generally is ineffective. And I think for a couple of reasons. In the case of somebody like that baseball player, who is really ideologically opposed to wearing masks and now sees not wearing a mask as a political statement, I think that trying to shame him into changing his behavior actually will cement his resistance. And then in other ways, I mean, when we think about, you know, not just that small minority of people who are actively resisting, but maybe the larger proportion of people who are very well-intended about masks, and don’t always wear them in the same way that some people are well-intended about condoms and don’t always wear them, I think when we shame those people also miss an opportunity to try to overcome the barriers that they’re experiencing. So when we tell people this is so easy, why can’t you just do this? And when people say, well, I find it uncomfortable and it makes it feel like it’s hard to breathe, and we just dismiss that as whining, we miss an opportunity to problem solve and to try to figure out how we can overcome those barriers. And that’s the kind of public health approach that actually works. And it’s something that has worked fairly well with condoms and I think would work fairly well with masks too. And we need to kind of get out of this mindset of hashtag wear a damn mask and actually hear people and give them a chance to tell us why it’s hard for them so that we can overcome those barriers.
Jordan: Well, you mentioned condoms and that was a big part of the way you explained it in the Atlantic. Can you outline how messaging on condoms evolved from stuff that wasn’t working, to what we eventually learned how to do?
Dr. Julia: Well in the early years of a AIDS, you know, it was kind of a similar situation in some ways, in that there was a lot of fear about this deadly virus and a need for a community, particularly the gay male community, to adapt, to figure out how to live with it. And the public health messaging in those early years was often moralistic and fear mongering and associated condomless sex with, you know, death and having a bad reputation and promiscuity and recklessness. Whereas using a condom was seen, or tried to be messaged as virtuous. And that kind of messaging did not really speak to people because what matters to people about sex is not virtue. It’s actually enjoying themselves. And so when condom campaigns started to centre that concept of pleasure, which is really the main reason many people have sex, they became much more effective and were heard much better. And that’s kind of been a theme throughout HIV prevention over the years, is this lesson that we keep learning over and over again, that when we try to try to shame people into changing their behaviour, it really doesn’t work. What it does is it makes them not tell us about their behaviour, but it doesn’t, it doesn’t make them not do it. You know, another thing that worked with condoms that I think could be really helpful with masks is innovation in design. So hearing people’s concerns about, you know, they’re uncomfortable and I don’t want to wear this thing all day. It doesn’t feel good. Okay, well, let’s make better masks. And finally, let’s make them free and easily accessible and really ubiquitous where they are most needed. We know that putting bowls of condoms in gay bars is effective because that’s where, you know, that’s kind of a touch point for where they’re needed. And similarly, you could imagine dispensers of disposable masks at that the front of a subway, trains and buses and places where we really want people to wear them. So instead of putting the onus on every individual to fold up their old t-shirts and make masks with rubber bands, let’s actually provide them with the masks that we want them to be wearing.
Jordan: You mentioned that pleasure is at the centre of the messaging around condoms. What should be centered in terms of the messaging around masks, if we wanted to accomplish the same thing? Like what facts do we have to acknowledge and allow people to sit with, rather than shame them for?
Dr. Julia: Well, ideally we would be doing research the same way that we were able to do over the years with condoms, to actually do interviews with people and surveys and understand what the barriers are. We don’t really have the luxury of time right now. But we can try to understand to the best of our ability what those barriers are. And yes, there’s a group that believes it’s an infringement on civil liberties, but there are also people who find them uncomfortable, for whom it makes them anxious. And I think ultimately for many people, masks are a visual and constant reminder of the fact that we are living in a pandemic, and they obstruct social connection. And those are very real concerns that I think have been dismissed in public health messaging. So I don’t actually have all the answers about what messaging would address those concerns, but I do think we need to have those concerns at the forefront of our minds when we put together any kind of public health messaging around any intervention, really just thinking about what matters to people here? And why is it hard for them to do this? And how can we directly address that so that they really hear that we understand it and that we’re still telling them, we think this is still important, even though we hear why this is hard for you, and here’s why we think this is important, and here are ways that we might be able to help you overcome some of those barriers.
Jordan: In America, particularly have masks become too politicized to reach that, you know, really high clients rate that the studies show can drastically reduce infection? I mean, I think that the stuff we’ve seen up here says, you know, 80 to 90% and all of a sudden you’re really knocking down the risk of infections. I can’t imagine 80 to 90% of Americans agreeing on anything right now.
Dr. Julia: Yeah. I mean, it’s valid to feel pessimistic. But I do think we may get there. Slowly over the past few weeks, we have seen more and more Republican elected officials making statements about masks and wearing masks. And even yesterday, President Trump saying he’s good with masks. So I think as things get worse here, we will see more people get on board. And I think with any public health intervention, it takes some time. And I think mandates, the more that they happen, as much as they are fraught in some ways, and very difficult to enforce and especially difficult to enforce equitably, I think mandates will increase compliance. So I think there is hope that we will get there. And my hope is that we get there soon.
Jordan: Is it taking America in particular so long, just because of the, I don’t know that the spirit of independence? Like it does seem like there’s, and I don’t say this in a bad way, but just as a general observation, that there’s that kind of a rebellious instinct in many Americans.
Dr. Julia: There is an emphasis in this culture on personal liberties that I don’t think is universal. But I don’t think that’s the only thing going on here. I think there’s a lot at play in terms of the current administration and just sort of generally the current political climate that make it really difficult for public health to do its job. And then I think some of the onus also lies in public health itself and the way that it’s been messaging throughout this pandemic in a way that I think is somewhat paternalistic and could benefit from more compassion for the general public and what they’re experiencing.
Jordan: Julia, thank you so much for helping us understand this today.
Dr. Julia: Thanks a lot for having me.
Jordan: Dr. Julia Marcus of Harvard Medical School and of the Atlantic. That was The Big Story. Please wear a mask. I’m asking you nicely. If you would like more from us, you can head to thebigstorypodcast.ca. You can find us on Twitter at @thebigstoryFPN. You can write to us, email us anytime, you can even email us video clips or audio clips. The address is thebigstorypodcast@rci.rogers.com. And of course we are in every podcast player you could ever dream up. If you create a new one, please make sure we’re in it. Thanks for listening. I’m Jordan Heath-Rawlings. Have a great weekend. Stay safe. We’ll talk Monday.
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