March 24, 2023

UAB has dropped their mask requirement for clinical spaces as of this week. I keep forgetting and automatically putting it back on when I leave my office and head for the exam rooms. Some patients are glad to be rid of them. Some feel more secure in enclosed space still wearing them. I’m taking my cues from the patients and their families. I don’t mind much either way. The VA is keeping its mask mandate for clinical encounters for now so I wear one when out on house calls. I’ll take it off if the veteran or family desires or if we’re sitting out on the porch or otherwise outside. It’s just another physical reminder that we’re moving beyond the pandemic and going back to before. Or are we? I don’t think that’s even possible. We can only go forward, never back.

When I think of how masks and mask wearing became such a cultural flashpoint about two years ago with various factions in high dudgeon over their use, this dropping of mask requirements in health care seems like a whimper and not a bang. I never could understand why people were as het about them as they were. Those of us in health care have worn them in sterile settings as a means of infection control for well over a century without ill effect. And there are cultures where facial coverings are considered entirely appropriate in public. Just because they had never been part of Eurocentric American cultural roots shouldn’t have made them anathema. People can get weird, and then double and triple down rather than admit that they might have been in error in regards to their first impulses.

Did masks work? That question seems to be coming up a lot in the pandemic revisionism that seems to be making its way through political public health circles. There’s been major cherry picking of data to try and downplay the use of masks, social distancing and all of the other tools we had prior to vaccines and a lot of very bad public policy is being enshrined in law in more conservative states to prevent quarantines, shutdowns, mandatory masking, or other tried and true measures due to their inconvenience and economic consequences. We can do that, but if a really bad virus gets out and into the population, something with a mortality rate of 10 or 20%, we’re going to wish we had those tools quickly without having to go through the process of repealing ill thought out laws. In general, the consideration of the did masks work question depends on your definition of work. Did they slow spread and flatten the curve in the first year or so of the pandemic? Yes they did. Did they prevent infection over the long term? That’s not as clear but everyone that had their infection delayed until after they were vaccinated had a much lower chance of death, hospitalization and/or the development of long Covid symptoms.

Far better public health minds than mine are now sifting through three years of pandemic data and looking for the various trends that can explain who got sick, who did not, where the hot spots were and what the true risk factors for significant morbidity and mortality were. What seems to be falling out of that data is that vaccines are life saving. Will we need more? That’s unclear but it looks like the elderly (of whom I will soon be one) and those with immunocompromising conditions (about 3% of the population) may benefit from repeat immunization. We should have additional data on this in the next few months. Other things that have fallen out: the various social determinants of health status had a huge impact on which populations carried the brunt of infection related damage. Poor, marginalized populations with less access to health care had much higher rates of morbidity and mortality. Politics played a factor. Those in blue states and communities had significantly lower rates of negative outcomes than those in red states and communities.

The data will parsed and analyzed and many learned papers and policy reports will appear. I have no idea if we’ll have learned anything from all of it however. As it’s likely to be another generation or two before the next major pandemic hits, I have a feeling we’ll have forgotten most of the lessons we’ve learned as a society about all of this, most of those reports will have been misfiled and we’ll have to go through this all again. I’m not likely to still be here at that point and some future person will have to chronicle that process in his or her own accidental plague diary. I hadn’t looked at the numbers for a bit, but we’re still at about 20,000 people hospitalized in the US, 3,000 of them in the ICU and 250 people dying a day. It’s been a leisurely decline through the spring but remains at a rate that will kill about 100,000 a year – twice as many as the flu in the worst flu years and five times as many as a normal flu year. And it will remain in the top five causes of death.

The social forces that were parading in the streets against public health measures and masks a couple years ago seem to have all gotten together to save the children from drag queens, Dolly Parton songs, Michelangelo’s David, musicals based on 75 year old New Yorker cartoons, and even a whisper of talk about gender and sexuality in the public schools. Per usual, whenever a new social movement appears to erupt everywhere at once, I have two questions. The first is cui bono? Who benefits? and the second is where’s the funding coming from? I have a sneaking suspicion that the answer to both questions is the same. The forces poised to make big money from the privatization of public education. There are a number of very powerful people out there who wish to continue to move of the commons to for profit enterprise and they’re ready to take on the education system after having marched through health care, corrections, utilities, the military, and other previously publicly funded endeavors. Erode trust in public education, offer a viable alternative outside the public funding stream, tailor your message to certain political and religious world views and voila – you can sell copyrighted curricula through private academies via instructional staff who are at will employees that can be easily cowed and replaced.

I also suspect that the right’s huge win with the Dobbs decision on abortion has added fuel to the fire. With the success at restricting abortion and women’s rights in conservative states firmly in place, there needs to be another bogeyman to keep the faithful in line and to keep the dollars flowing. Drag queens and the transgender community (conflated by some but having little to do with each other) are an easy target. Laws are being passed where the cruelty is the point. What I don’t understand is where is the allyship in all of this? I haven’t heard much of anything out of the Human Rights Campaign or the Democratic party organizations in terms of push back. Have they just written these tiny populations off as expendable? Because it won’t stop there. As these forces feel emboldened, they will take more and more steps toward eliminating what they feel are heretical lives and behaviors. I’m not expecting to be loaded into a boxcar yet but I’d like to see things stopped well short of that point and not much seems to be happening in terms of organized resistance.

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