After lockdown, we will need masks more than ever

Nepal will open its 2021 lockdown long before the country has enough vaccines to protect its citizens -- our aunts, uncles, and neighbours. We will not have substantial vaccine coverage for many months, if not longer.

We will need more oxygen, more testing, and better tracking and isolation procedures. Crucially, we will also have to maintain and strengthen our only effective tools: physical distancing and masks.

Unfortunately, too many Nepalis are wearing low-quality masks, taking them off too often, touching them, and not washing them or replacing them often enough. More people should be wearing three-layer surgical masks, which, for only a few more rupees, offer greater protective power.

The key problem Nepal faces has not changed: infected people do not know they have the virus and spread it around. And new variants make the virus even more easily transmissible. We need to behave not as if only a small number of people could have the virus, but as if everyone we encounter already has it. That includes the friendly neighbourhood fruit seller. That includes family members. That includes you.

“Vaccinations will take a long time to arrive in South Asia to create a wall of immunity. Till then, masks are most essential,” says Mushfiq Mobarak, a Yale university professor who recently led a huge study of mask-wearing in Bangladesh.

Many Nepalis wear cloth masks or one-layer surgical masks. These help, no question. But the 3-layer surgical masks and N95s offer more filtration efficiency and more protection, although they cost just a few rupees more. That is an investment well worth it to protect individuals, institutions, and governments.

This projection by the Institute for Health Metrics and Evaluation (IHME) of the University of Washington School of Medicine in Seattle shows that in Nepal 1,000 fewer people will die by 1 September if 95% of people wore masks while outdoors. Source of all graphs: IHME University of Washington / Nepal Ministry of Health and Population

I asked Biraj Vajracharya, an epidemiologist at Dhulikhel hospital, what kind of mask people should be buying and wearing. "Surgical mask, or if possible, N95 mask," he replied.

The Yale researchers recommend high quality 3-layer masks because they filter more efficiently. They can be washed and reused without losing much efficiency. For more on the study's recommendations about masks, see this excellent video.

"We need to change mask-wearing norms amongst hundreds of millions of South Asians to mitigate the spread of COVID," Mushfiq Mobarak told me via email. "High-quality washable, reusable surgical masks are much more cost-effective, and offer a feasible path to scalability across the region."

The Yale study in Bangladesh, involving over 300,000 people in 600 villages, identified simple policies that led to much greater mask wearing. They found that when authorities do four things together, mask wearing more than tripled:

  1. Offer free masks
  2. Provide clear information about mask wearing in videos and brochures
  3. Find community leaders to speak in support of mask wearing
  4. Reinforce the message with gentle questioning for those not wearing

The fourth policy was the most important: special monitors to verbally poke people who were not wearing masks. Those monitors, the Yale study explains, ‘walk around and if somebody is not wearing a mask, they intercept them and politely say, “We distributed masks here—why aren’t you wearing one?” If the person didn’t have a mask or couldn’t get one, the monitor gives them one.’

What this combo of four actions does is establish a community expectation, a clear norm or standard for the community to follow. The norm shows everybody that the community expects them to wear the masks, that it takes masks seriously. That makes a big difference.

The researchers call their recommended program NORM:

No-Cost masks

Offering Information

Reinforcement in public places by intercepting non-mask wearers

Modelling and endorsement by trusted leaders

Here's some useful mask info:

  1. All masks help, but 3-layer surgical masks and N95 masks offer greater protection.
  2. Double masking is good, especially with low-quality surgical or cloth masks.
  3. Masks should cover the mouth and nose. A tight fit on all four sides is good.
  4. If you touch the mask, you should wash your hands.
  5. Masks should be washed and replaced regularly.
  6. In general, you should wash your hands with soap several times a day.

A historical reminder might be relevant here: when we think about the Covid-19 vaccine, we often recall the big health breakthroughs of the past, such as the discovery of the polio vaccine in the 1950s, and penicillin in the 1940s.

But long before these headline-stealing medical heroes arrived to save the day, death rates had already dropped dramatically in Western Europe and North America. This health revolution came because of much less glamorous innovations: clean drinking water, efficient waste disposal, increased bathing, and expanded soap use.

These basic sanitary measures saved millions and millions of lives. In Nepal in 2021, basic preventative measures such as physicall distancing and careful mask wearing can save lives as well.

One other reminder: last year, after we were released from Lockdown I in July, Covid-19 infections spiked. After Lockdown II was lifted in September, infections spiked again, reaching their highest level yet. The end of Lockdown III will likely bring new risks.

Tom Robertson, PhD, is researching the environmental history of the Kathmandu Valley.

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