Masking the World

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Dr Balakrishna Poduval
Dr Balakrishna Poduval
Dr Balakrishna Poduval was Former Professor, Homi Bhabha National Institute, Former Head, Immunology & Hyperthermia Section, Bhabha Atomic Research Centre. PhD guide at HBNI dnd Mumbai University. He along with his team at Bhabha Atomic Research Centre has contributed immensely to original knowledge in the area of Immunology and Critical care medicine which is highly relevant to the current crisis. He also has papers in the area of septic shock and heatstroke. He Can be contacted at [email protected] * Views are personal.

Wearing a mask by common people has become mandatory during the current viral infection causing COVID-19. This is the first time in the history of mankind; every citizen is forced to use the mask to prevent the infection from spreading. The medical practice until this pandemic was to use the mask only by medical staff to prevent the infection from passing on to the immunocompromised patients. The use of face masks on healthy people during the coronavirus pandemic has been a major point of contention and confusion among scientists and the public. There is a predominance of scientific literature to disapprove, the continuous use of a mask by common people, to prevent respiratory infection. In contrast, not nearly as much literature has been put out to describe or argue for the other possibility – mask helps in containing the respiratory infection (Journal of Paediatrics and Child Health 56:976, 2020).  

My goal here is to use scientific evidence and logical thinking to evaluate, and legitimate, the possibility that Mask causes more harm than good. Importantly, I will base my reasoning and fact checks on solid, credible evidence; which includes data from published scientific journals, World Health Organization (WHO), Centre for disease control (CDC) the USA, Ministry of Health and family welfare-Government of India (MoHFW) and Indian Council of Medical Research (ICMR). I am sure the thought processes (Mann Ki Baat) will be heard by our leaders as they are very much interested in our health and happiness.

Let us look at the advice given by various Medical bodies, who look after our health.

Advisory by Health Institutions regarding Covid-19:

  1. WHO (5 August/7 June): Non-medical, fabric masks are being used by many people in public areas, but there has been limited evidence on their effectiveness and WHO does not recommend their widespread use among the public for control of COVID-19. However, for areas of widespread transmission, with limited capacity for implementing control measures and especially in settings where physical distancing of at least 1 metre is not possible – such as on public transport, in shops or in other confined or crowded environments, Governments can encourage the use of the mask.
  2. MoHFW has not issued any guidelines recommending wearing of a mask if someone is driving a car or cycling alone, a top government official said on Thursday (3 September). ICMR in its website listed many variables causing varied results of RT PCR in relation to the viral load in Covid19 patients. They state that there is no correlation between viral load and Covid19 severity. ICMR’s Dr Raman R Gangakhedkar added that “There are no scientific studies to show the health benefits of wearing a mask for non-sick persons. Prof. Bhargava, DG, ICMR, advises frequent hand washing, intake of balanced diet and exercise along with practising adequate physical distancing and use of a mask in public and workspaces.
  3. CDC recommends that you wear masks in public settings around people who don’t live in your household and when you can’t stay 6 feet away from others. Masks help stop the spread of COVID-19 to others. This recommendation is based on what we know about the role respiratory droplets play in the spread of the virus that causes COVID-19, paired with emerging evidence from clinical and laboratory studies that shows masks reduce the spray of droplets when worn over the nose and mouth.
  4. In his blog post, the CSIR chief had referred to the findings of various studies and said that the emerging pieces of evidence and arguments suggest that airborne transmission of SARS-COV-2 is a possibility.
  5. CDC abruptly removes (24 September) guidance about airborne coronavirus transmission, says update ‘was posted in error’.

Proper use of Mask:

WHO said that community masking could lead to a “false sense of security”. The protection is dependent on the capacity of the fabric to bind the virus to the fibres so more layers of the right kind of fibre are better. Most importantly it must be a tight fit around the nose and mouth and washed at regular intervals, which is impossible to achieve with a surgical mask as well as most ordinary face masks. The mask used currently has no specifications regarding the material used, thickness and the number of layers.  Benjamin Cowling, Professor, WHO Collaborating Centre for Infectious Disease Epidemiology and Control, School of Public Health, The University of Hong Kong recognized that face masks aren’t a perfect public-health tool because they allow room for user error, a point made in the WHO guidance.

It is good to make a fashion statement about the use of mask but it more important to see that the virus is completely inactivated in the mask before it is being reused. Union Health Ministry advisory recommends washing masks with soap and hot water and drying in the sun for at least 5 hours. Alternatively, the mask can be boiled in a pressure cooker for 10 minutes or a normal vessel for 15 minutes. You can also apply heat on the mask for up to five minutes using an electric iron, after washing it with soap. Achieving this feat during the monsoon season by our people, who use Dupatta and handkerchief, is a daunting task.

Masking and Science Facts:

  1. During the 2009 pandemic of H1N1 influenza (swine flu), encouraging the public to wash their hands reduced the incidence of infection significantly whereas wearing facemasks did not (Epidemics 2017; 20: 1–20). There is no good evidence that facemasks protect the public against infection with respiratory viruses, including COVID-19 (Lancet Res med2020 May; 8(5): 434).  Surgical facemasks are designed to be discarded after a single-use. As they become moist they become porous and no longer protect. Indeed, experiments have shown that surgical and cotton masks do not trap the SARS-CoV-2 virus, which can be detected on the outer surface of the masks for up to 7 days. (Ann Intern Med. 2020 Apr 6: M20-1342, Lancet microbe,  1, ISSUE 1, e10, May 01, 2020).
  2. Spike protein of SARS-CoV-2 binds with high affinity to lung cells from humans, monkeys, ferrets, cats and other species with high receptor homology. Many cats have been tested Covid19 positive as per the CDC report. Then why we are not considering maintaining a social distance or try to mask cats and monkeys? (Virol. (2020). The virus can infect the eye and enter the lungs, but still, no advisory on covering the eyes is issued.
  3. The WHO and CDC have long held that coronavirus is spread primarily by large respiratory droplets when an infected person coughs or sneezes. Normal surgical masks have a pore size of approx 0.3-10 microns, and viruses are 0.004 to 0.1 microns in size. This can prevent spreading your body fluids like saliva and not virus to other persons. Professor John Oxford, a virologist at leading London hospital, The Barts and the London, said: “Really, there is very little evidence that masks actually offer much protection against flu.” 

A dead body does not release droplets and hence cannot spread the virus. Dead body is the least infective because unlike bacteria virus needs live human cells and the dead body has no energy to support the Virus growth. Under these circumstances, wrapping the body in plastic, which does not transmit the virus is the most inhumane treatment to the departed soul. By this logic, we human beings should move in the public encased in plastic shell.

  1. A meta-analysis done by Cochrane Collaboration on wearing the mask during surgery by doctors came to the conclusion that by wearing the mask, the chances of infection will not be lessened rather they will be increased(Cochrane Database Syst Rev. 2012;1(CD002929).
  2. Fourteen randomized controlled studies did not support non-pharmaceutical personal protection measures to prevent lab-confirmed influenza transmission (Emerg Infect disease 26:967, 2020).
  3. CDC report dated June 10, 2020, accepts that wearing a face mask for more than one hour, will cause physiological effects on the wearer since carbon dioxide is inhaled by the wearer. It may lead to problems like headache, increased pressure inside the skull, changes in the nervous system, increased breathing frequency, cardiovascular effects, and reduced tolerance to lighter workloads.
  4. Mask which is covering the nose and the mouth has the same temperature as our body. The action of speaking and breathing makes this area moist and nourishing caused by body secretions and becomes a fertile ground for bacteria and other infections to flourish ( Face mask causes stagnation/collection of all kinds of viruses (including Coronavirus) and frequent touching of the mask (23 times per hour), leads to virus spread. Thus, a presymptomatic or mildly infected person wearing a facemask for hours without changing it and without washing hands every time they touched the mask could paradoxically increase the risk of infecting others (Journal of Paediatrics and Child Health 56 (2020) 976, Am J Infect control 2015 Feb 1; 43(2): 112,  There are fewer data to support the use of masks or respirators to prevent becoming infected (Epidemiology Infection 2010, 138(4):449).

Emotional aspects Masking:

  1. Risk-benefit analysis has to be done, considering all the facts like hunger, depression, emotional distancing and domestic violence caused by Covid19 (Social distancing leading to Emotional Distancing and Pathetic condition of Indian migrant workers-a firsthand experience and domestic violence, Corona Pandemic-6 months down the memory lane). Masking prevents the exchange of smiles when we meet our near and dear ones. We have long known that emotions can affect health. Depression, anxiety and stress weaken our immune system, while happiness on the hand has been shown to boost our body’s resistance to disease.  There are 2,409 references on how emotions affect our immune system in Pub Med (Arch Otolaryngology Rhinol 4(1),27, 2018). When the immune system is weak the latent virus present in our body gets expressed leading to health issues. ( Medical Microbiology. 4th edition Baron S, editor. Galveston (TX): University of Texas Medical Branch at Galveston; 1996. Chapter 46 Persistent Viral Infections ).
  2. Studies show that there are both physiological and psychological benefits of maintaining positive facial expressions during stress. Smile Intensity in Photographs Predicts Longevity, and it can even lengthen our lives (Smiling activates the release of neuropeptides that work toward fighting off stress (Psychological Science, 21, 542, 2010, Seaward BL. Managing Stress: Principles and Strategies for Health and Well-Being. Sudbury, Mass.: Jones and Bartlett; 5th edition, 2009:258). The mask has robbed our smile.

Mask induces Hypoxia, Hypercapnia and increases body temperature:

Addressing the nation on Yoga Day 2020, our Prime Minister, stressed the benefits of yoga and how it is helping the world in the fight against coronavirus pandemic. in building immunity and resolving respiratory illnesses. ”Masking on a long term basis is the reverse of Pranayam where instead of allowing oxygen to reach the cells of the body, we are facilitating more carbon dioxide to reach our body tissues leading to both long term effects and short-term effects on our health collectively called Hypercapnia (Neurocirugia. 2008 Apr; 19(2):121-6). Pulse rates increase and SpO2 decrease after the first hour. Since a very small decrease in saturation at this level, reflects a large decrease in PaO2, the findings may have a clinical value for the health workers and the surgeons. Recent studies have shown that hypercapnia adversely affects innate immunity, host defence, lung damage and may contribute to poor clinical outcomes in patients lung diseases (Scientific Reports volume 8, Article number: 13508 (2018).

Face mask impacts brain human thermoregulation circuit and leads to an increase in the body temperature (The Annals of Occupational Hygiene 56.102,2012). During exercise, the need for oxygen which is about, 250 ml per minute in the resting stage can increase up to  5000 ml per minute(  Continuing Education in Anaesthesia Critical Care & Pain, 4,2004, 185).  Expired air with ventilation and sweating removes the extra heat generated as a result of increased metabolism during exercise. Use of mask in a hot and humid environment, for carrying out strenuous physical activities can contribute to deleterious health consequences.

Breathing Difficulty
Credit: Dr BR Choudhury, Nice way to Cure Covid-19

Hence wearing the mask for long time can induce symptoms similar to Flu like illness (see table).

Can you ignore Herd immunity data?

Studies were done by Tata Institute of Fundamental Research and ICMR (done on July 20), based on serosurvey, point towards herd immunity. It is heartening to note that this kind of herd immunity was achieved with very low Infection Fatality (Immunotherapy by Nature vs. Vaccine, COVID19 is a Flu-Like Illness). Please remember the absence of antibodies in seropositive people at a later point of time is not the absence of immunity. They would have developed long term memory T and B lymphocytes. In an age-structured community with mixing rates fitted to social activity, then the disease-induced herd immunity level can be ~43%, which is substantially less than the classical herd immunity level of 60% obtained through homogeneous immunization of the population (  Science 369, 846–849 (2020). Considering that the Indian population has more young and active people and the lockdown has been eased resulting in more human activities, we are at a comfortable level of herd immunity. Hence masking can be avoided and focus should be on personal hygiene, exercise and nutrition.


  1. A large %age of the population in our country is poor, living in slums. They cannot afford to buy masks though the government is trying to regulate the price (cost price + 45% as per the news papers) Hopefully the simplest mask of single layer of cloth may be available in future for <Rs.5, but I do not think they will buy a mask. They will continue to use a 'duppatta or any small piece of cloth'; one can see being used. Now the Government is inculcating fear by fining Rs 500 for not wearing the mask. So it will slowly become a norm to cover the mouth and the nose on the main roads by a piece of cloth which may be dirty; this will be worse than wearing a mask

  2. Yes Masks have become a matter of debate eg: The Municipal Commissioner ordering that people driving cars should wear mask. More than mask , it should be adequate facial covering in crowded situations to protect and prevent infection and spread.

  3. It’s really a comprehensive article with strong scientific arguments from various aspect including molecular virology, meta-analysis and epidemiological evidence. I agrre with your observation and scientific argument that continuos wearing of mask having adverse effect on emotional and physical health. Lack of proper guidelines of face mask quality and unavailability of recommended facemasks is added problem.

  4. A very good article with all supporting evidences. Analysis is excellent. Scientists are not able to give a clear picture of advantages of wearing a mask for various professionals and common public. Physical distance, fabric used, layers of fabric, cover for nose and mouth, duration of its use, its cleaning/ heat treatment, accumulation of unwanted stuff from mouth and nose, nerves near ears getting stressed, increase in BPM, gasping for breath after walk etc.all taken into account in the article. Probably wearing the mask will cause major health hazards.
    So the conclusion by Dr. Balakrishna Poduval is correct.

  5. Comprehensive article, well-researched with adequate references, describes pros & cons about use of face masks. The scientific facts and figures presented should sensitize logical mind on their indiscriminate use. It’s time to rethink with balanced approach before clamping a statutory requirement. Various circumstances and factors should be taken into account before taking a policy decision. Hopefully, competent authority will take note with appropriate revision.


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