The Evidence Is In: Population-Wide Masking Was a Spectacular Failure

On March 8th, 2020, Dr Anthony Fauci, then one of the most prominent figures representing the official global response to the Covid-19 outbreak, stated on 60 Minutes that “right now, in the United States, people should not be walking around with masks…When you’re in the middle of an outbreak, wearing a mask might make people feel a little bit better…it might even block a droplet, but it’s not providing the perfect protection that people think…it is.”

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Within less than a month, Dr Fauci did a sharp U-turn. On April 3rd 2020, he recommended on PBS that people wear “some sort of facial covering” when they leave their home and go about their business. He justified this change by pointing out that evidence suggested the possibility that people could transmit Covid without showing any symptoms. Yet, even if people could transmit the virus without displaying symptoms, this hardly changed the evidence around the efficacy of masks at blocking or reducing viral transmission.

So what changed between March 8th and April 3rd 2020 to convince Dr Fauci to reverse course and claim masks were a critical tool for fighting Covid-19 in the general population? Scientifically, nothing had changed. Fauci’s own previous scepticism about masks was more than justified, given the glaring absence of rigorous evidence showing they worked to stop respiratory viruses from spreading between persons. What did change was that the public health establishment decided, for whatever reason, to start making masking recommendations unsupported by any compelling scientific evidence.

Governments across the world jumped on the bandwagon and followed Fauci down the path of first recommending masks, and soon mandating masking in closed spaces, and sometimes even outdoors. This was very disappointing, because it represented the hijacking of the public health establishment by a “pro-mask agenda” that swung free from rigorous scientific evidence.

It is not that we had definitive proof that community masking was completely useless. But there was a high degree of uncertainty surrounding mask studies, and the most rigorous types of study - RCTs (randomized controlled trials) - failed to show in any consistent way that masks made any significant difference to the spread of Covid-19 or other respiratory viruses like the flu.

If you have been paying attention to mask evidence reviews coming out of the World Health Organisation, the Oxford Centre for Evidence-Based Medicine, the European Centre for Disease Prevention and Control, and Cochrane (an internationally respected institute that produced “synthesised evidence” on a range of issues including health), you will have noticed that whatever their pragmatic recommendations on masking may have been during the pandemic (WHO and ECDC, for example, recommended the use of masks in community settings), they all admitted in their scientific reports that the evidence supporting mask efficacy in community settings was at best, “weak to moderate” in its level of certainty.

Now, Cochrane has come out with an updated review of the mask literature, published on 30th January 2023, which essentially reinforces the conclusions of multiple reviews by other scientific bodies. This updated review includes a total of 78 RCTs (randomized controlled trials) to see where the balance of evidence pointed. The authors of the study conclude that “the pooled results of RCTs did not show a clear reduction in respiratory viral infection with the use of medical/surgical masks. There were no clear differences between the use of medical/surgical masks compared with N95/P2 respirators in healthcare workers when used in routine care to reduce respiratory viral infection.”

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Yes, the Cochrane study comes with its caveats, such as risk of bias in the trials and inconsistent adherence to the interventions. But the fact is, the study just reiterates what we have known all along, namely that the evidence supporting community masking as a strategy for blocking transmission of Covid-19 or any other respiratory virus in the real world (as opposed to in a highly controlled laboratory setting) is flimsy and inconclusive at best. And you don’t recommend a population-wide intervention or behaviour - let alone impose it coercively - based on flimsy, inconclusive scientific evidence, or a “gut feeling” of some public health officials.

Dr Fauci had it right back in March 2020, when he said that a mask might block a few droplets, and might make you feel a little better during an outbreak, but “doesn’t provide the perfect protection that people think it does.” Fauci was dead right when he said that “there’s no reason to be walking around with a mask.”

These were probably the truest words Fauci ever uttered about masks.

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1. Here are some more details from the findings of the Cochrane study:

On medical/surgical masks compared to no masks:

Wearing masks in the community probably makes little or no difference to the outcome of influenza‐like illness (ILI)/COVID‐19 like illness compared to not wearing masks (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.84 to 1.09; 9 trials, 276,917 participants; moderate‐certainty evidence. Wearing masks in the community probably makes little or no difference to the outcome of laboratory‐confirmed influenza/SARS‐CoV‐2 compared to not wearing masks (RR 1.01, 95% CI 0.72 to 1.42; 6 trials, 13,919 participants; moderate‐certainty evidence).

On N95/P2 respirators compared to medical/surgical masks:

The use of a N95/P2 respirators compared to medical/surgical masks probably makes little or no difference for…laboratory‐confirmed influenza infection (RR 1.10, 95% CI 0.90 to 1.34; 5 trials, 8407 participants; moderate‐certainty evidence). Restricting pooling to healthcare workers made no difference to the overall findings…One previously reported ongoing RCT has now been published and observed that medical/surgical masks were non‐inferior to N95 respirators in a large study of 1009 healthcare workers in four countries providing direct care to COVID‐19 patients. 

The authors’ conclusion on the efficacy of masking:

The pooled results of RCTs did not show a clear reduction in respiratory viral infection with the use of medical/surgical masks. There were no clear differences between the use of medical/surgical masks compared with N95/P2 respirators in healthcare workers when used in routine care to reduce respiratory viral infection.

The authors’ caveat:

The high risk of bias in the trials, variation in outcome measurement, and relatively low adherence with the interventions during the studies hampers drawing firm conclusions. There were additional RCTs during the pandemic related to physical interventions but a relative paucity given the importance of the question of masking and its relative effectiveness and the concomitant measures of mask adherence which would be highly relevant to the measurement of effectiveness, especially in the elderly and in young children….There is uncertainty about the effects of face masks. The low to moderate certainty of evidence means our confidence in the effect estimate is limited, and that the true effect may be different from the observed estimate of the effect.