UCSF Doctor Explains Petition Against Masks

Contributor
Graduate Division

Editor's Note: Last month, Dr. Jeanne Noble joined other UCSF docs in petitioning Gov. Gavin Newsom to drop mask mandates. On Monday, Newsome announced California would lift mandates on Feb 15. In our latest podcast, Dr. Noble explained her decision to take a stand, especially when it comes to children. Listen to the Q&A on SoundCloud.

Over the murky horizons of Omicron and potential new variants, making policies in relation to COVID are still extremely difficult due to its huge unpredictability.

As the Omicron wave dips, we have had a number of diverse views within UCSF with regard to mask mandates, the most hotly debated being that on masking policies within schools.

Being curious about health policies and outcomes, I sought to educate myself better on this issue by reaching out to UCSF faculty on both sides of the debate to learn more.

First up is Dr. Jeanne Noble, an associate professor of Emergency Medicine at UCSF. Dr Noble’s petition on removing the mask mandates in schools caught my attention on a twitter feed debating the need for masks as COVID cases fall and we prepare to transition from pandemic to endemic COVID. The interview transcription has been edited for clarity and conciseness.

Janice Goh

Thank you so much for agreeing to do this with us.

Dr. Noble

Thank you for having me. Appreciate it.

Janice Goh

Could you share with us like, what is your background? And how have you been involved in the COVID? pandemic?

Dr. Jeanne Noble

Dr. Noble

I'm associate professor of Emergency Medicine, here at UCSF. I am the director of COVID response for the UCSF Parnassus emergency department. Prior to COVID, I was in charge of disaster preparedness. And then, when COVID hit I pivoted to be the COVID Director. And from pretty early on, at least by let's say, the fall of 2020, I became an advocate for what I consider to be evidence-based policies for children at school. And it was a little bit of a natural extension, because I was advising other hospitals on testing and cohorting patients trying to [determine] how could we keep everybody as safe as possible during this pandemic. And then I started getting invitations to speak to schools and to school districts, to superintendents, about COVID safety policies. And when I did that, and really started to dig into the data about kids and COVID, and whether schools were super spreaders, etc. I started to advocate for what I considered the best cost benefit analysis for children. Clearly children, from my perspective, needed to be in school, and how could they do this safely? As an emergency physician, we do see and treat kids in distress. And looking at the data from our UCSF pediatric hospitals, we were seeing a real uptick in the number of adolescents who were coming in, in mental health crisis, we had concerning signs of increasing number of kids coming in with suicidal ideation and increased hospitalizations for eating disorders and anxiety disorders. So that was all trying to try to get out in front of all of this and say, Look at the whole child, what is their COVID risk? What is their mental health risk? And how can we help protect and advocate for our kids? And so that's how I got into it initially. And, boy, sometimes it feels like we've come a long way, and sometimes it doesn't.

Janice Goh

These are also things that many adults have reported facing, things like stress, depression, and so on from just being in lockdown and having restrictions. Was there an enrichment? Or were children a more impacted group?

Dr. Noble

I solicited the data from the California Department of Public Health and received in 2021, the completed suicide numbers for California for 2020. And there was a 24% increase from the prior year of the number of people under the age of 18 who committed suicide in in California. And then it went up from about 107 to 134. During 2020, the number of adults, people 18 and older in California who committed suicide actually declined by about 11% during that time. So we don't have data on causation, certainly. And what we saw [...] just looking at raw suicide numbers is that kids were faring worse and [it was] hard not to be concerned that it didn't have something to do with the prolonged isolation. Kids in California had just about the longest social lockdown of any place in the country and were out of school for an average of 18 months. And even if their absence of being able to socialize with others was not the cause of a worsening mental health crisis, it certainly didn't help it. As physicians, we recommend if anyone is suffering from significant depression, anxiety, etc. the first step in the recovery is normalization of routines. It's going to bed at the same time getting up at the same time getting out of the house, exercising, interacting with other people expanding your network of trusted confidant. And all of those things are taken away during school closures.

Janice Goh

Can I learn more about your stance on the current COVID masking policies?

Dr. Noble

In 2020, pre-vaccination, I was as pro-mask, as you get. I made YouTube videos about how to make a mask out of a kitchen towel. I was pushing for masked mandates and fines associated with that. It felt like that was one of the only tools we had in our toolkit. And even if it was only modestly effective in preventing the spread, we didn't have much else we could do. The message was please just mask up. Now post-vaccination, things got very confused, because a lot of us felt like, once the vaccines arrived, as long as they were as effective as advertised — and they performed amazingly well — those risk mitigation layers like masking would fall away. And they did for a short period of time last summer. And then they were brought back and it was very confusing messaging like Wait, yeah, vaccinated person I need to mask and is that to protect the unvaccinated? Or is that actually to protect me? And there was very, I think muddled messaging from the CDC on down. And for kids masking in school — their education indicators have really plummeted. I mean, kids who can't read at grade level and can't perform math at grade level have gone gone way up, mental health indicators are still poor. And so thinking like, how can we get kids back to normal? And how can we have them have the most enriched educational environment to try to make up for everything they've been through. And masking is a problem. It's really hard for English language learners, when they can't see the lips of the speaker, it's hard to understand nuanced speech. It's hard for all of the kids who have language or speech challenges. So there's a lot of reasons to get rid of mask if they're not really saving lives. And the data for masks is really quite weak. It's in the category of modest to marginal, which I think it still made sense to push masks when we didn't have vaccines. But now that we have vaccines, it really needs to be under the microscope. Exactly how effective are masks? And there's only two randomized controlled trials that exist for masks stopping the transmission of COVID. And one was negative — that was done in Denmark in 2020. It did not show a benefit and reduce transmission from COVID for mask using, for mask wearing. The second one was done in Bangladesh, led by researchers from Yale and Stanford. It was also pre-vaccination, and they found a very modest benefit for surgical masks and not cloth masks. So they found cloth masks did not stem the transmission, did not lower the transmission risk for COVID. And that surgical masks did but only in the subgroup over the age of 50, which of course, is not your average K through 12 students. That was a relative risk reduction of around 10%. The Bangladesh authors released their raw data about six or eight weeks ago, and they actually only had a 20 case difference out of about 9,000 participants. So there was roughly 4,500 people in the mask group and the unmask group, and there were only 20 more cases in the unmask group, which is not an absolute 10th percent reduction. It's far from it. And that was one of the main studies that was touted as you know, "Masks are really a key intervention to reducing transmission." And the Bangladesh study on close analysis doesn't show much benefit at all. I mean, it's very, very modest in the order of less than 1% in terms of an absolute risk reduction. And so then there's another set of studies that the CDC has touted quite a bit in schools [...] in Arizona looking at Pima County in Maricopa County and saying outbreaks of COVID are three times higher in the schools without the mask mandates. But they didn't control for vaccination rates. And this has been a problem with a lot of studies, because counties and communities that have high vaccination rates tend to have the toughest mitigation measures too, they tend to have the mask mandates. And we know that our vaccines are incredibly effective. And the effect of masks layered on top of that you have to control for because you would expect many more outbreaks in schools where there are fewer people vaccinated. So we still to this day, do not have a single high quality study showing that student mask wearing decreases transmissions in schools. And because we have that lack of data, and we have concern about harms, just in the things that I already mentioned, it's decreasing the quality of kids' educational environment, and it's particularly hard on the most vulnerable students and English language learners. So if we don't have data of benefit — and a significant benefit — and we're just assuming that some small amount of benefit is there, but we have growing evidence of harms, it really violates one of our basic principles in medicine, which is to first do no harm. And now that we have vaccines available for all school aged children, and we're coming up on 12 weeks since they were approved for our five to 11 year olds, it really seems time to let our kids get back to normal, stop the mask mandates. And then people can feel free to mask as long as they as long as they are uncomfortable unmasking. It's not saying we need to prohibit masks. But we need to stop peeling back the mandates and really help our kids get back to a normal educational environment.

Janice Goh

In the Bangladesh study, did they explain why the masks didn't really work in an unvaccinated population? Because through the pandemic, everyone has been telling me COVID is an aerosol airborne disease. So it's very shocking to find that masks didn't help as much as we thought they should.

Dr. Noble

Yeah, it is really interesting. I have to say, when I first started looking at the data, I was shocked. But looking back when before this issue became politicized [...] there was not a consensus actually pre COVID, that masks actually helped reduce the spread of influenza and other respiratory diseases. There was a very open question with really nebulous conclusions. And there's actually even a study of surgeons wearing surgical masks in operating rooms, and not really finding a benefit there in terms of provider to patient protection. We have lots of mannequin studies that show masks are very good at containing droplets. And we went from those mannequin studies to real world applications without that intermediate step of, Do the masks perform on people like they do in the lab? What I think is so regretful about the CDC promoting masks almost on par with vaccines is I think we have a lot of vaccine hesitant people in the United States still, and that is our biggest problem. And we took away the incentive [...] to get vaccinated by saying they didn't even get to take off their masks when they got vaccinated. And if you were somebody who didn't trust the vaccine, you didn't really want to get vaccinated, and then you took away sort of the prize for getting vaccinated, that's problematic. And then the second thing is that I think it really undermines people's confidence in the power of these vaccines. I mean, the vaccines have been performed incredibly well. For the average person, two doses has been highly protective against hospitalization and death. And now boosting our more vulnerable people above age 60 or people who are fragile medically, adding on that booster dose has retained the same incredible protection against serious illness and death. And that is something to be widely celebrated. But when we put masks up there as, even the vaccinated even the boosted have to mask, I do think it's very hard to argue at the same time that these vaccines are highly protective. Because if they were, why do I still have to wear a mask?

Janice Goh

A lot of the reasons why masks were being brought back was because we were starting to see breakthrough infections, especially with the Delta variant, even before Omicron. And so that was what actually caused the messaging to become muddled. And so what are your thoughts about this?

Dr. Noble

Omicron changed things for a wider audience in terms of masks, because I think people decided that Omicron was so infectious. But by that same token, being more infectious or more easily spread, people became quite concerned that actually our masks were not doing that much, that they weren't good enough. And so we came to this fork in the road, where either we were going to say masks were never that great, and now with Omicron, they're, like, useless, so let's forget about the masks. Or, a lot of people in bluer cities, if you will, I mean, places that have felt like the masks are really important kind of political message, have said, "No, we just have to up our game in terms of masks. We're not going to get rid of masks, we're just going to KN-95 and N-95." And it causes the same problem, because we don't have much data for KN-95 either except on mannequins. And in that transition from mannequin studies to real life application with, with cloth mask and surgical masks, everything fell apart from a scientific point of view. And so it seems like a really opportune time to just say, You know what? Omicron is a less virulent form of COVID. The mass data was not very robust to begin with. Vaccinations are important, they're widely accessible. Let's just move on. That, of course, is the path that I have chosen. And I think the California Department of Public Health is actually — I think we've taken the same branch point there. Because they have not said KN-95 or N-95 are required for schools. They have come out and said, "No, we are not going there. We are not saying that these types of masks are now required because Omicron is more infectious and the cloth masks and the surgical masks don't really do much." They've just continued to say, "Wear a well fitting face mask period, it doesn't have to be of any certain type." So they have dodged the plea to say we need we need tighter fitting masks. And I'm hopeful that our mask mandates will go away on February 15th.

I would like to see them drop it for, for kids in schools at the same time that they drop it indoors for adults. And I mean, that's based on two things. One is the fact that kids are at the lowest risk from COVID of any demographic group that we have. So even the unvaccinated child has about a flu like level risk for serious illness and death from COVID, which is not at all the case for the unvaccinated adults. So the unvaccinated child was never asked to mask pre COVID. And they of course, have vaccines available to them now. And then teachers have had vaccines and boosters, really, since the beginning. I was one of the physicians who advocated to put teachers first in line for rolling them out to frontline providers. And they are a well taken care of group. So, it would be justified from both a public health standpoint, in terms of kids being low risk at baseline, having vaccines available, and two, from the harm reduction perspective, that the average child is masked for at least six hours a day, five days a week, which is more than most adults. People working from home are not masked at all, or if they're in a stable group, they don't have to be masked anymore. And our kids have the most to lose from masking. I mean, they're trying to learn language, they're trying to learn to interpret complex facial expressions. Somebody smiles behind their mask and child is struggling — an adult is struggling — to say, is that smile? Are they happy? Are they nervous? Are they embarrassed? It's an impediment to their development. And so they should really be first in line as we pull back mask mandates.

Janice Goh

My understanding is that the vaccines haven't been approved for [children].

Dr. Noble

All school aged children, and this does not include preschool, our vaccine eligible. It may be that the six-months to four-year-old vaccine will be approved by the end of the month. Pfizer has just submitted its data and so that that should come soon. But any kid who is in any child who is in a K through 12 setting, has now had the opportunity to be fully vaccinated.

Janice Goh

With any policy, all policies are a double edge sword, right? And for new COVID policies, they can be extremely emotional, especially for parents because their children are also at stake. So even though there could be good evidence about taking away the mask mandate in schools. Is there a chance also that there may be a huge number of parents who would decide, If you're taking away the mass mandate in schools, I'm also taking my kids to school?

Dr. Noble

Yeah, that's a great question. I do think that the biggest obstacle right now to normality is fear. I mean, it's policy, but then what happens when the policies change? There's still a lot of fear and we've done an excellent job of scaring people about COVID. I mean, my fear of COVID ended about a year ago last month when I became fully vaccinated as a frontline health care provider in January of 2021. And I think that it will take time for people to feel okay to go around without masks. I mean, you get out of the Bay Area, you only have to get about 45 minutes out of the Bay Area, and there's like not a mask in sight. So it is a little bit of a, it's a regional or geographic issue. I don't think that parents will pull out their kids in mass. I think that people will be nervous, but they can continue to mask their kids until they're comfortable having their kids go to school maskless. And that's okay. I mean, people have been through a lot, and there's so much mixed messaging out there, and it's really hard to follow the data. So I think that's perfectly fine. And then the very small number of highly vulnerable people associated with our educational settings, be they teachers, or students, should consult with their physicians to decide about their mask strategy. If we have a kid with leukemia who's on chemo, their physician may really double down and decide, we need to try to get this kid fit tested for an N-95. It's just these blanket mandates to have, you know, 6 million kids in California massed six hours a day, five days a week, to protect the less than 1% highly vulnerable, it's just not a cost effective strategy. And it doesn't pass that harm benefit analysis.

Janice Goh

What about the risk of new emerging variants? I've been reading a lot about it, that it's possible the next variant could be just as contagious, but more deadly than Omicron. So actually relaxing masking policies now be potentially detrimental?

Dr. Noble

The masking policy I just don't think is particularly effective anyway but there’s no reason that you can’t bring it back. So say, worst case scenario after Omicron, there's another variant that's even more infectious, but is more deadly. You know, it wouldn't be a bad idea for our public health agencies to really put some money into studies about different kinds of masks, KN-95, etc. to see exactly the impact they have, and how effective of a tool are they. Because we know of the downsides, but it is really important as we layer on risk mitigation, and then pull it back, that we that we have a quantitative guess at least as to the amount of impact that's going to have. More than two years into this, we really don't know that number. We just don't have robust data to tell us that our mask mandates really do much. We looked at a couple of different school districts and counties in Florida and Tennessee, in North Dakota, looking at schools that have mask mandates and those that don't with similar vaccination rates. There's no difference in the school transmission. So I don't look at the mask mandates is a critical piece of our COVID response.Maybe that will change if we fund and find some really good data supporting how effective masks are. And if we do there's no reason that we can't bring back masks as needed.

Janice Goh

Thank you for taking your time to share this with us. It's very insightful. Oh, yes, of course.

Dr. Noble

Thanks for reaching out