Mask History

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Two weeks ago, I wrote about viruses and briefly touched on the use of masks to prevent the spread of diseases. Today, I would like to look at the interesting history of mask use. Mask wearing to prevent the spread of disease is an old idea and can be traced back to the 17th century. Back then, doctors wore odd costumes that included full facial masks, often bird-like in appearance, when they treated victims of the plague. People then had intuitions about epidemics spreading through foul odors or miasmas in the air. The advent of bacteriology and germ theory in the 1880s gave the old idea of face masks new relevance. Surgeons wore face masks (plus gowns and gloves) in new state-of-the-art operating theaters in the early 20th century.

In September and October of 1918, an influenza pandemic, erroneously called the Spanish flu, began sweeping the country and the world. While estimates of the number of fatalities differ, it is estimated to have killed at least 20 million people worldwide. Frightened people turned to a new version of an old method of protecting themselves – face masks. It seemed logical for citizens to turn to masks during that flu pandemic to protect themselves. But much like today, a simple intervention of wearing a mask quickly became imbued with broader, often political, meanings. Public health campaigns agued that mask wearing was a public duty. Not everyone, however, was convinced. Mask “slackers” asserted their rights, rejected public health advice, and refused to wear them (sound familiar?). In San Francisco, a short-lived anti-mask league raised money to fight against enforcement of mask ordinances. There were fights, shootings, and murders when mask advocates and mask slackers clashed.

After the pandemic died down, scientists spent decades studying and conducting experiments on the usefulness of masks to prevent disease spread. They used high-speed photography to analyze the extent to which cloth masks (that was all they had then) were useful in containing droplets ejected during a cough or sneeze. Soon after the development of the electron microscope in 1931, viruses were discovered. Their existence had been suspected for years but they were too small to be seen until the advent of the electron microscope. Scientists soon realized that viruses could easily pass through the large pores of cotton masks. Then, in the 1960s, masks made from new synthetic fabrics replaced cotton masks. These masks had much smaller pores and were more effective against viruses.

For most of the 20th century, masks attracted little public interest and were relegated to medical uses and use in dusty environments. That changed in 2004 and 2005 when another respiratory epidemic – SARS – spread from China throughout the world. Many people, especially in East Asia, turned again to masks to protect themselves. Even after SARS was eliminated, it wasn’t uncommon to see people in many Asian cities wearing masks to protect themselves from pathogens and allergens.

President George W. Bush developed the Strategic National Stockpile (SNS) to store pharmaceuticals and medical supplies, including masks. At its peak in 2006, the SNS held more than 100 million N95 masks. When a new flu pandemic struck in 2009, the Obama administration distributed many of the masks in the SNS but didn’t replace them. Nor did the Trump administration. Then, in early 2020, with the advent of another Chinese virus, COVID-19, government officials had a problem. Fearing mask shortages, they decided to concentrate the limited mask resources on hospitals and advised the public against mask use. Then, once mask supplies recovered, they reversed themselves and advised people to use masks. But the damage had been done. The flip-flop fueled a resurgence of the age-old resentment of mask mandates, a battle that is often as violent as it was in 1918 and continues even today. To paraphrase Santayana, those who do not know the past are doomed to repeat it.

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 By Peter Galvin, MD

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