8. The end (of masks) is near.

Off-ramp is a just few miles up ahead.

In my community, masks are still seen in most places. In the stores, in university lecture halls, and on almost every child in school. But when and why and where should we begin to ease up on mask requirements?

Answers: Sooner than later, because risk is decreasing, and everywhere with high vaccination rates and low community transmission.

Masks are still strangely controversial

There has been an awful lot of bluster about masks over the past year and a half. To set the record straight: Masks do not cause facial deformities, nor do they turn children into social zombies. They also are not face diapers (author’s note: it’s generally not advisable to take public health advice from a Florida burger joint.)

Masks also do not reduce risk to zero - nothing does that. But public health risk management is about playing the odds.

Mask controversies, on the other hand, are manufactured, focus-group tested outrage meant to stir up anger and resentment in people by implying that they are some threat to liberty, when in fact, the threat itself isn’t liberty, but contracting a life-threatening infection. The scientific community knows that a) a sizeable fraction of Covid transmission arrives in the form of droplets or aerosols in air, b) masks are reasonably effective at keeping these droplets away from a mask wearer, and c) masks also reduce the droplets exhaled by someone with an infection. Full stop. That’s a scientific analysis based on fact, not opinion-driven political views.

Despite the lingering anger and vitriol, and persistent political skepticism, I do think for many, the end of masks is sooner than later.

Making decisions in a broader framework is important

Community decisions on universal masking must be driven by public health data, and not political motivation. Perhaps more important is that everyone also has to use the same playbook - to date, it’s a hodge-podge of standards that can vary from town to town, or sometimes even within a single school district. These decisions cannot be based on who was last elected to your local town government, school board, or county sheriff.

Here’s a start - public health data has to include at least the following metrics:

High community vaccination rates for all eligible recipients (now, 5 years old and up)

Low community transmission rates as defined by the CDC

The detection of outbreaks in the community that might not be detected by crude transmission rates

In highly vaccinated communities with low transmission rates and no outbreaks, we should be comfortable relaxing mask requirements. Wear them if you want, but don’t make them mandatory. The risk of acquiring an infection remains low, so the benefit from wearing a mask remains low.

What are these specific metrics? This is where I acknowledge my own expertise limits. I am an exposure scientist, not an epidemiologist. I can tell you how droplets float through the environment or how they enter our airway to increase our risk of infection. I can’t tell you what the precise community transmission rate needs to be in order to suffocate a pandemic, or how this might change with different variants.

Fortunately for us, there are loads of outstanding, data-driven epidemiologists and infectious disease clinicians who fill the halls of the CDC and state public health departments, and who are ready and willing to make these recommendations. In fact, the CDC already publishes some guidelines to this effect, but they are wonkish and difficult for the public to interpret, and they are buried in technical webpages.

I do think a mask-free future is nearby, however. Covid is on the decline, and vaccinations are on the rise, both welcome developments. For communities who are doing their part to keep transmission rates low, I see mask requirements ending by the end of 2021.

Two steps forward, one step back

Covid hotspots will continue to pop up from time to time. While I would expect to see this in the least vaccininated communities, that won’t always be the case. Covid can return anywhere, especially when we head indoors taking respite from the cold, large events like concerts reappear, or unmonitored outbreaks spread undetected through communities. Even in highly vaccinated Vermont, a small liberal arts college outside of Burlington had 77 new cases last week; in the prior two months, they had recorded a total of 11 cases. This is a prime example of where we have to be prepared to take a step backwards.

When this happens, we should consider temporarily returning to mask requirements, based on whether a community exceeds these metrics. Most people own a few masks - just hang on to them a little longer, and take them out only if they are needed.

But if we don’t take preventative action, we run the risk of uncontrolled community transmission rates which lead to even more stringent and dramatic interventions. Absolutely no one wants to the return of closed businesses and schools. The United Kingdom is currently learning this very lesson, where tens of thousands of kids are infected, and hundreds of schools are experiencing outbreaks.

We also must acknowledge that schools represent a potential reservoir of virus because of the lower (but growing!) vaccination rate in children, the very limited testing that occurs in this population, and that many kids are asymptomatic carriers who remain undetected. In many ways, infection rates in children are a proxy for the broader community. As a result, I think opt-out (and not opt-in) pool testing is a cost-effective strategy for keeping an eye on Covid across this population and needs to be part of the conversation.

While I hope we can win every battle and win the war, I also accept that not every battle will be won. We have to be prepared to take a step backwards every once in a while. Accept a short term defeat and fight again. A short return to masks is not admitting defeat - it’s an act of courage.

A plea for authoritative leadership

There is still a real danger where local decision-making leaders act as armchair epidemiologists who are responding to misinformation. At the beginning of the pandemic, public health expertise was viewed with hostility, and was marginalized and trivialized as a nuisance. In doing so, it empowered thousands of local decision makers to assert authoritative expertise when there was none. Instead of a single captain in charge of a single ship, we have thousands of little boats sailing in all directions, many of which are operated by people without proper (or any) training.

And there is little doubt that this political influence has lead to more sickness and death than was necessary.

It is time to call on the Centers for Disease Control in the US to take a hierarchical leadership approach to guide the nation with well-defined consensus metrics. What community transmission rate is acceptable? How does one define a community outbreak? What community vaccination rate is required? And is a one-size-fits-all set of metrics acceptable for all, or are there susceptible populations where different metrics are more appropriate?

In other words, set the targets. Speak clearly and loudly. Show us the way, get out of the way, and local public health officers will take care of the rest.

National leadership is what makes state leadership work well, because it gives public health directors advice that is uniform, apolitical, and is a result of scientific consensus. State and local leaders know their communities best, and can provide the essential data that is needed to act and protect their communities. But local leaders need a coherent framework to follow. Without it, we govern by opinion polls and memes.

Some states have public health officials who question vaccines or refuse to wear masks around immunocompromised people. These states will probably continue to ignore CDC guidelines. If so, it would seem reasonable that the federal government apply leverage to these locations to require compliance - with all due respect to Hawaii, no state is an island in the United States.

There is precedence for this; the 1984 Minimum Drinking Age Act (23 U.S.C. § 158) signed by President Reagan comes to mind. If you don’t care that an outbreak in your state is spilling over to infections in other states, you figure out how to pay for your highways. That seems fair to me.

Mask-free Future Ahead?

The purpose of masks is to reduce risk of infection in areas where infection risk is high. When these external risks are lowered, mask wearing becomes less effective and less necessary. The cynic in me says that masks will be a part of our national strategy for many more months, or even years, because Covid is endemic, and is unlikely to disappear for many years. So I’ll be hanging on to my masks. For the communities that are following public health guidance, I am hopeful that these masks will remain mostly on the sidelines.

But without national compliance, and lacking a national strategy, I fear these hot spots will never go away completely. And they will become a persistent and pervasive worry when we gather together with friends and family.

To those states, and their political leaders, who erroneously believe they know more than the public health scientists: you will be the skunk at the picnic.