Why our public health leaders didn’t push face masks early and are now regretting it

(Kevin Dietsch | AP) Director of the National Institute of Allergy and Infectious Diseases Dr. Anthony Fauci wears a face mask as he waits to testify before a House Committee on Energy and Commerce on the Trump administration's response to the COVID-19 pandemic on Capitol Hill in Washington on Tuesday, June 23, 2020.

In a recent Pew survey of American adults, 65% said they wore a mask all or most of the time when inside of stores or businesses. However, only 44% said they thought that all or most of the people in their community wore a mask.

Why are so many Americans not wearing one? To answer that question, I’m going to ask another.

Do you remember the book “Natural Cures ‘They’ Don’t Want You to Know About?”

Written and self-published by Kevin Trudeau, it was a compendium of alternative medicine that was wildly popular in the mid-2000s. My family had a copy, and we certainly weren’t alone. In one three-week period in 2005, it was outsold only by the latest “Harry Potter” book, reaching No. 1 on The New York Times bestseller list for weeks.

It was also full of insane quackery. He told people to stop taking all prescription and nonprescription drugs, all vaccines. He said that sunlight doesn’t cause skin cancer, but sunscreen does. He wrote that “antiperspirants and deodorants contain deadly poisons.” He called AIDS “one of the greatest hoaxes ever perpetrated on the American public.” Then, he told people the real cures for diseases could be found on his website, where he sold subscriptions for $500 a pop.

Trudeau is currently in jail for violating the terms of a 2004 settlement he agreed to after the contents of another book he wrote were found to be “grossly misrepresented.”

Certainly, Trudeau’s book found success with some of the people who have now decided against wearing a mask: those who simply don’t trust the medical community. These people are the types that call mask wearers “sheep.” These are “anti-vaxxers.” These are people who are very active on social media today, and no amount of evidence could dissuade them. You probably know someone who is in this group.

Most of the time, this is the major informational war the medical community wages. There are too many of those people, enough to push a book to the top of a bestseller list. But those people are a strict minority: 84% of Americans believe that vaccinations are extremely or very important. The medical skeptics aren’t enough to explain the low mask adoption numbers.

So what does? More than the “They” distrusters, there’s a larger group of people who are essentially reasonable, but a little set in their ways. To budge them into doing something, you have to communicate consistently and fervently about an issue.

With masks, we failed at this communication. And the reason why still ties into quack medicine but in a more roundabout way.

Thanks to books and information like Trudeau’s, doctors constantly have to persuade their patients that alternative medicine isn’t enough to make an impact.

Sometimes, horror stories are enough — Steve Jobs, the Apple founder, famously regretted embracing alternative medicine instead of opting for surgery to deal with his pancreatic cancer. Sometimes, humor works. There’s an old joke: “You know what they call alternative medicine that has been proven to work? Medicine.”

In fact, a high bar of proof is required — and rightfully so.

[Read more: Coronavirus treatments are improving. Here’s a guide to what works and why.]

It is not a surprise that the quack medicine machine has been hard at work during the coronavirus pandemic. For example, here’s a study that was released in March that argued that “natural garlic essential oil is considered as a valuable resource recommended for preventing SARS-CoV-2 invasion into the human body.” They did this by looking at the chemical structure of garlic essential oil, then the chemical structure of the part of the human cell that the coronavirus connects to, and in computer simulations, the garlic could connect to it, too. They even included their own graphics.

One questionable study tried to tie garlic to the prevention of coronavirus through this unhelpful figure.

Figure 1 is hilarious nonsense. It’s a smushing together of clip art with sciencey acronyms and chemical shapes surrounding a picture of garlic so that people think garlic is good at stopping coronavirus somehow. Heck, even if garlic attaches to these cells, what does that mean? Does garlic connect better than the virus? We don’t know. What happens if garlic does, anyway? Half-baked doesn’t begin to describe this study. (“Dicey” might.)

To prevent studies like this from making it into actual medicine, scientists usually require the “gold standard” of studies before making alterations to their practices: randomized controlled trials, or RCTs. Those are studies in which there are two groups that are randomly selected, while remaining as similar as possible. One gets a treatment, one doesn’t. It’s even best if doctors and patients don’t know which group is getting the treatment and which isn’t, a process called blinding. Then, you compare the two groups to see how effective the treatment was.

We’ve recently had large-scale RCTs in remdesivir and dexamethasone that found them effective in treating the coronavirus. In fact, that’s why we were so excited about those treatments when compared to other studies. Most of the other promising studies are just observational; we noticed that some people who were given some treatment improved but didn’t know how to compare it to a baseline of people who didn’t get the drug. With remdesivir and dexamethasone, we know, so we moved those treatments into the prescribed standard of care.

And this is where we get back to face masks: There just isn’t the big RCT about mask-wearing in the general public preventing transmission during a pandemic.

[Read more: The real story about asymptomatic people and whether they spread the coronavirus]

To be clear, there’s evidence that says wearing a mask helps block the virus. Clearly, studies have shown that masks — blue surgical masks, N95 masks, or cloth masks — block some percentage of even the tiniest particles, like those the size of the virus. Masks of all types certainly block a large percentage of the speech, sneezing, and coughing droplets that cause most disease. There are clear RCTs about the importance of masks in health care scenarios — that’s why we have long seen doctors and nurses wear them.

There are also observational studies that show benefits for mask wearing in terms of transmission. Here’s one systematic review of such studies. For the coronavirus in particular, Paul Sabin, a Brigham Young University alum, recently found a correlation between states that had mask mandates and declining effective transmission rates. You can do the same thing on the country level as well: Places like Japan and Hong Kong with high masking rates have had better than expected experiences with the pandemic.

But because there wasn’t that big RCT about public masks during a pandemic, the default position for years of both the World Health Organization and the U.S. Centers for Disease Control and Prevention was that masks weren’t recommended — and it wasn’t just because a shortage was feared. For example, during the H1N1 pandemic in 2009, the CDC didn’t recommend wearing a face mask or respirator in most scenarios.

The problem is that our desired RCT of “public mask usage” is really hard to pull off. Even when we did tell a group to wear masks, there were compliance issues: Only a fifth of people in one attempted RCT reported wearing the masks consistently. Tracking people all day is essentially impossible for researchers. And while I wish we would have completed one, at this point, we may not even want to do an RCT. It might be downright unethical to tell a control group not to wear a mask during a pandemic.

In my opinion, the lack of an RCT shouldn’t have been where the big health organizations shut down, but instead the opportunity to look at the other research for our best data available. That data indicated strongly that masks helped in health care settings, and that masks of all types block viruses to some extent. Given that, shouldn’t the default have been the logical outcome — the one telling the public that masks helped, even the homemade ones?

Instead, the leaders in our medical community went wishy-washy. On Feb. 29, the U.S. surgeon general begged people not to buy masks, saying they were “not effective in preventing general public from catching #coronavirus.” On March 8, Dr. Anthony Fauci went on “60 Minutes” and said “There’s no reason to be walking around with a mask.”

That means that the curmudgeonly group of reluctant mask wearers had a lot to hang their hat on: the literal words of the nation’s top health officials from three months ago. Given the inconvenience, that doubt is enough to keep them from wearing a mask most of the time in businesses. Meanwhile, I’m sure Trudeau’s folks are throwing a parade.

The result of mask reluctance has been that politicians are having to catch up and force adherence to mask wearing through regulation. Gov. Gary Herbert is poised to grant Salt Lake County Mayor Jenny Wilson’s request to the state that the largest county make masks mandatory within businesses.

Quite frankly, if volunteerism in mask wearing were widespread, we wouldn’t have to do that. We could have avoided this growth in cases and hospitalizations altogether: A 20% additional reduction in transmission rate would have been enough to squelch the virus in Utah. Instead, we’re at risk of careening out of control.

Yes, the anti-science crowd is still primarily to blame on both fronts, and they should be roundly criticized. It is unforgivable to dismiss science to that extent in 2020. But mistakes have been made by our leaders, too, in the way they’ve communicated with the public about what we know and when.

By now, the scientific community has all come around on the fact that it’s time for people to wear masks. The WHO, the CDC, the Utah Department of Health, and Herbert fervently agree: Masks are the Natural Cure “They” Do Want You to Know About. I just wish this bestselling book had been published sooner.

Andy Larsen is a Tribune sports reporter who covers the Utah Jazz. During this crisis, he has been assigned to dig into the numbers surrounding the coronavirus. You can reach Andy at alarsen@sltrib.com or on Twitter at @andyblarsen.