A mask is never just a mask

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Thomas Schlich is the James McGill Professor in the History of Medicine at McGill University, and a former practising physician.

Bruno J. Strasser is a historian, a professor at the University of Geneva, and an adjunct professor of the History of Medicine at Yale University.

They are the authors of The Mask: A History of Breathing Bad Air.

On a full bus in any Canadian city, you might see just one or two people wearing a mask – if any at all. This is only a few years after we all wore masks on buses and in other crowded places. At the time, many believed masks might become the new normal. Yet, as with many other lifestyle changes COVID-19 imposed upon us, that hasn’t happened. Still, this universally shared experience has made masks into the most visible symbol of the public-health measures enacted to fight a pandemic.

A mask is never just a mask – a simple piece of protective equipment. Masks carry historical baggage and cultural meanings, which are deeply personal. As a result, wearing one is never a neutral act. Masks mean more than any other devices used for personal protection, like seatbelts or helmets. One reason is that our face – more than any other part of our body – defines who we are. Yet the significance of covering one’s face depends on context. In 19th-century France, masks were unpopular among male physicians and factory workers, as they were seen as a sign of weakness and thus unmanly. Meanwhile, in China, masks were viewed as unsuitable for women because they were deemed inelegant. During the COVID-19 pandemic, public-health authorities largely overlooked the fact that masks had long been gendered – so it came as a surprise when men were the most resistant to wearing them.

During the pandemic, some people thought it was ridiculous to wear a mask. To make their point, a few individuals took to the streets wearing the most famous mask of all: the plague doctor’s beaked mask. This striking facial covering was used to make a statement about the futility of public-health measures – and to ridicule them.

The beaked mask is deeply embedded in our collective memory of past pandemics, but like any memory, it is fallible. As we discovered, the plague doctor’s beaked mask was never real. The well-known engravings that emerged in the mid-1600s were satirical, not accurate depictions of the protective equipment used at the time. These images mocked plague doctors as greedy, overly verbose and harbingers of death rather than recovery. Representing them in an imaginary crow-like costume was a powerful way to make these points. Masks, it turns out, have had a bad reputation for a very long time.

For many, masks seemed not only ridiculous but also foreign. In the West, they are often perceived as part of an imagined Asian culture. Yet for much of the 20th-century, masks were considered foreign in many Asian countries as well. In Japan, at the turn of the century, they symbolized Western chic, as Japanese doctors imported them from Germany. In China and Korea, masks were associated with Japan, since colonial authorities imposed their use throughout the empire, including in Manchuria and on the Korean Peninsula. In 1920s Shanghai, masks were seen as a British import and imposition. Like epidemics, masks always seem to come from elsewhere.

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More than any association with gender, style and geography, masks embody political values. The debates over mask mandates during COVID-19 exposed deep political fault lines. Never before in history had entire populations been required to cover their faces. While there were mask mandates during the 1918–19 influenza pandemic, they were short-lived and limited to a few municipalities, mainly in the United States. Even then, these measures provoked reactions that revealed the core issue: Many believed their bodies should be beyond government control. In San Francisco, people were fined and arrested for going out without a mask. Some even claimed they would rather die than be forced to wear one – likely an exaggeration, but it underscores that the dispute was not only about health. At its heart, it was about the balance between individual freedoms and societal obligations, as well as the rightful role of medical experts in a democratic society.

As with any other prescriptive measure, no amount of scientific evidence can decide whether masks should be mandatory. Such injunctions have always been political decisions. But there is a further limitation to how science can inform practical matters: science is inherently complex and uncertain. At some point during the pandemic, we all asked ourselves: Are we safer with a mask? Are we protecting those around us? Or simply following official recommendations? Health authorities flip-flopped several times on these issues. Masks were first deemed useless, before they were declared indispensable. No wonder many people were left puzzled about the efficacy of masks – a warning about the danger of oversimplifying scientific issues.

The science behind mask efficacy has always been debated. Even in the highly controlled environment of an operating room – where masks have been worn since 1895 – their effectiveness has been surprisingly difficult to establish. This doesn’t mean we are clueless. It means that scientific knowledge evolves, that it always carries some degree of uncertainty, and that it applies only to specific conditions and narrowly defined questions.

The claim that science has proven masks “work” (or don’t) is meaningless without specifying what “working” means. Protecting the wearer’s health or the health of those around them? Preventing the projection of saliva droplets or filtering incoming microorganisms? Safeguarding individuals or entire populations? Discussing the efficacy of a given mask is only meaningful once these distinctions are made explicit. Recommending surgical masks for self-protection against aerosols, as many health authorities have done – even though these masks are designed to protect others from droplets – lacks scientific support and risks undermining public trust in experts.

Even when facts are not absolutely certain, science can still guide decision-making. In the 1960s, quitting smoking was a reasonable choice, even as the tobacco industry pointed to gaps in the epidemiological evidence linking smoking to cancer. Similarly, during COVID-19, it was scientifically reasonable for an elderly person to wear an N95 mask when visiting a hospital, just as it was reasonable for a teenager to forgo a surgical mask while running alone in the woods.

The scientific knowledge needed to make an informed decision about masks is complex, but not so complex that it cannot be conveyed to a lay audience. When experts and health authorities underestimate the public’s intelligence, they risk squandering the trust that has been placed in science. Humility and sincerity are crucial in fostering the trust necessary for constructive public dialogue about how we want to live together, both during pandemics and during normal circumstances.

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Another lesson we learned from COVID-19 is how dependent our health care systems have become on single-use products, such as masks. For decades before the pandemic, national-health authorities around the world planned for future epidemics. Yet when COVID-19 struck and governments mandated masks, shortages emerged almost immediately – even in China, the world’s leading manufacturer. In Canada, as in other Western countries, commentators attributed the shortage to disrupted global trade, offshored production, and insufficient strategic reserves. But the deeper issue was our dependence on disposable masks and other medical devices rather than carefully sterilized, reusable alternatives.

Until the 1970s, reusable cloth masks were the standard. However, aggressive marketing by manufacturers promoted the idea that disposable masks were cheaper, safer and more convenient. These claims were not only based on dubious evidence but also concealed the consequences of shifting from reusables to disposables. In times of crisis – whether a pandemic, war, or trade war – supply chains inevitably become strained, leading to shortages. And it’s not just masks; syringes, scalpels, speculums, catheters, ventilators, and intravenous bags have all become single-use. In some cases, manufacturers have deliberately designed these products to be impossible to sterilize with standard methods, thereby preventing their reuse. National regulatory agencies have also discouraged – or outright banned – the reuse of medical devices. It is time to reassess the true cost of disposables in health care and their environmental impact.

The mask craze of the COVID-19 pandemic reveals something deeper about our societies: the allure of the “technological fix.” Rather than addressing the root causes of complex societal problems, it is often easier – and more seductive – to offer simple technical solutions. Just as it is tempting to rely on carbon capture technologies or nuclear power to solve climate change rather than tackling emissions at their source, it is tempting to mandate masks instead of confronting the systemic issues that make populations vulnerable: the decline in hospital capacity since the 1980s, the impact of modern lifestyles on chronic disease, and the role of air quality in respiratory health.

Masks can be a reasonable emergency measure, but few of us want them to become a permanent way of life. Too often, masks are required to breathe safely in polluted cities and toxic workplaces. It is time, then, to design a world where we can all indulge in the simple pleasure of taking a deep breath – without having to worry when, where, or why to wear a mask.

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