Thoughts on the Mask Wars

5 min read August 31, 2020 at 9:42am

My last post on anxiety around infection and personal protective equipment was close to five years ago. Not all that much has changed, really, except the scale.

Today, in both the Sydney Morning Herald and the Insight blog from the Medical Journal of Australia are what are essentially hit-pieces on current PPE guidelines for COVID-19. This is on top of the twitter mob which has been rather upset with me for suggesting that droplet precautions are adequate in Queensland (and posting a photo putting my money where my mouth was). 

Pandemics are scary, that's not news (my talk on bioterrorism [pdf] has some more background), and as with all of the rest of healthcare, the biggest problem is communication of nuance in the setting of uncertainty and anxiety. Somewhere along that road, the dialogue now seems to have shifted to:

  1. The infection control guidelines are wrong
  2. The Infection Control Expert Group would rather die on their hill than admit error
  3. Infectious experts are the wrong people to be making these decisions

I can't remember the last time that I saw clinicians attacking another group of clinicians about their area of specialty in the mainstream media.

Certainly in the early days of thrombolysis for acute stroke there was robust debate in the literature (which as I recall seemed largely to be along ED vs Neurology lines), but there was never the level of personal acrimony directed at individuals - especially the Infection Control Expert Group - that we're seeing now. 

Feel free to blame social media and the decay of humanity if you'd prefer to here, but I think this is really a response to the anxiety of clinicians in a time of great crisis.

This is not really any more an argument about right-or-wrong, or "you've not found the gotcha paper that I'm referring to, otherwise you'd see the wisdom of my correct point of view".  It's an argument about values, and uncertainly, and risk tolerance - which are inherently subjective.

While I had thought about creating a list of the articles which I believe support the arguments of ICEG (there are plenty), and the reasons which I don't agree with the supporters of universal, fit-tested N95s (there's also a few of those), I accept that it's actually completely pointless. Evidence won't change the mind of the angry and the scared.

Instead, I'm going to reflect on the "ivory tower" argument, and the "hubris of experts" discussion that's been going on.

The Infection Control Advisory Group (ICEG) have responded to the earlier criticism that the membership wasn't public by publishing it here. Given the way they're being slandered on social media, you don't need to wonder too hard why they didn't.  I've met more than half of them and know them all by reputation.

You can read their bios on the ICEG website, but suffice it to say that a good number of them still work clinically including clinical infection, managing infection control programs and at the bench in the microbiology lab. Those that don't still actually work there were practicing clinicians (and experts of the "commissioned government report author" calibre) when I was a medical student. One of the group told me that they'd estimated between them they have 330 years of infection prevention experience.

The last meeting I had including one of the members of the group, they were wearing scrubs (for what that's worth as a marker of being a "front-liner"). One of the ICPs on the group has been sent from their substantive job to assist in outbreaks in aged care and in correctional facilities - both much higher risks than the acute hospital setting.

It's also patently ridiculous to assume that because someone has a university title that they're removed from the front-line, given that basically every clinician has the opportunity to take on a clinical teaching role if they want it (and the group is made up of experienced clinicians).

There have been many calls for the expert group to include fewer experts, and more non-experts. Which have, of course, been phrased as a "desire for greater diversity" in representation.

I'm not sure if anyone really thinks the opinion of an ID physician is super-valuable in how an obstetrician delivers babies, or a surgeon cuts a thing or an ED physician runs a trauma, or a physicist interprets a particle flow experiment. What I really struggle with is that the "ID are bad, wrong and evil" brigade are largely quoting academic non-clinicians as the desired experts. To supplant the "ivory tower, non-frontliners" who are apparently too far removed from clinical medicine to be able to make good decisions. It really baffles me.

Regardless of your interpretation of the evidence, or your degree of anxiety about COVID or your proximity to someone with an actual case, the question that I keep coming back to is this:

Why would you assume that someone working on any aspect of infection would be doing anything but their best in the middle of a pandemic?

Does anyone really truly believe that anyone would make a recommendation that they didn't honestly believe was in the best interests of staff?

Do you truly think so little of your colleagues, that you'd accuse them of actively placing you in harm's way?

Isn't 2020 a bad enough place already?