Why some health experts worry that Philly’s switch on masks may backfire

As Philadelphia’s health commissioner during the early years of the AIDS epidemic, Stuart H. Shapiro knows what it’s like to run a big-city health department during a crisis. The evidence keeps changing, yet the guidance has to be updated in a way that inspires public cooperation and trust.

That’s why it was smart for Philadelphia to establish clear COVID-19 benchmarks in February, spelling out what levels of cases and hospitalizations would trigger requirements such as masks and proof of vaccination, he said. But now that those metrics have been cast aside as of Thursday, Shapiro worries that the abrupt reversal may backfire.

“It’s totally confusing,” he said. “It takes away confidence in science-based criteria.”

Another former health agency chief, previously skeptical of Philadelphia’s decision to become the only big city to resume an indoor masking requirement, praised its decision to replace its mask mandate with a strong recommendation to mask up.

“They did the right thing at the same time, which is to highly recommend the use of masks,” former Baltimore health commissioner Leana Wen tweeted Friday. “Remember if you wear a mask to please wear a well-fitting N95 or equivalent.”

The mask conundrum is the latest example of the challenge that has plagued health agencies since the start of the pandemic. The evidence from the real world is not always clear-cut, yet the health officials must translate the nuance into a straightforward message. And when that message works — in the sense of preventing disease — it’s easy for detractors to claim afterward that the caution was unnecessary.

When the guidance is changing, it’s exhausting.

At this stage of the pandemic, it may make more sense to emphasize education rather than mandates, said Brian Zikmund-Fisher, a professor and expert in health risk communication at the University of Michigan School of Public Health.

”There are always going to be some people who, for various reasons, reject requests by public health officials to take precautionary measures,” he said. “What I most want to reach is the larger number of people who are just trying to do the best they can.”

There is good evidence that masks can reduce the spread of disease, he said. But in practice, he said, they may not work as well as intended due to lax enforcement or if people wear masks that are ill-fitting or made of flimsy material.

“The conversation ought to be about raising people’s awareness of when and where risk is higher, and encouraging people continually to try to take precautions that are appropriate, acknowledging that we are not going to be perfect, and that’s OK,” he said.

Local health departments need to normalize mask-wearing by sending a clear message that periodic masking will be part of the public health strategy for a long time, said physician Georges Benjamin, executive director of the American Public Health Association.

Health officials similarly issue heat warnings or ozone warnings, urging people to stay indoors during extreme heat or poor air quality, he said.

“There will be days we need to wear a mask and days we don’t need to,” he said. “As long as the health department is using data to drive public health announcements and not being bullied by politics, it’s OK, and they can maintain their trust. But they have to fully explain why the change, because if they don’t do that, the next time they really want people to put masks on, no one will follow their advice.”

On Friday, Philadelphia health commissioner Cheryl Bettigole rejected any suggestion that the quick reversal on the mask mandate could hurt the health department’s credibility.

“I very much take seriously my obligations to say things that are true to Philadelphia and to keep my promises,” Bettigole said. “I had said when I announced this that if we didn’t see hospitalizations rising that we needed to rethink this and that we shouldn’t have a mandate in that case.”

COVID hospitalizations in the city rose earlier in the week, following an increase in cases, but both numbers have since declined slightly. Everyone hopes that widespread vaccination, along with the immune response induced by prior infection, will make severe COVID a thing of the past.

Yet Shapiro, the former city health commissioner, cautioned that it was too soon to conclude that hospitalizations have declined for good. That’s because when people are hospitalized with COVID, it can happen weeks after the onset of illness.

“Historically, the hospitalizations rose two, three, or four weeks after case counts rose,” he said.

If there is agreement on one point, it’s that everyone is wiped out. And that makes the job of public health officials harder, said Michigan’s Zikmund-Fisher.

”Part of the problem with these reversals in guidance is that we aren’t appreciating how hard it is for people to be making day-by-day decisions about what’s safe to do, and what’s not.” he said. “It’s hard enough that the statistics are changing and the numbers are changing. But when the guidance is changing, it’s exhausting. It’s literally exhausting.”

He added:

“The decision you made last week no longer applies,” he said. “We have not appreciated the levels of cognitive and emotional exhaustion, what some have called decision fatigue.”

Staff writers Sarah Gantz and Jason Laughlin contributed to this report.