Medical Examiner

A Public Health Expert on When She Will and Won’t Wear a Mask

Two women in masks walk through a mall with shopping bags.
You should still mask up at the mall, at least for a little longer. Spencer Platt/Getty Images

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There’s this old episode of the TV show Candid Camera I kept thinking about this weekend. In it, an unsuspecting person gets into an elevator with a bunch of people who work for the show.

And the Candid Camera people start doing weird stuff in unison. They all turn to face the back of the elevator. They take off their hats. Then, they put their hats back on. And every time they do something, the person who’s stuck in this elevator with them ends up doing whatever the group around them is doing. No matter how absurd.

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For me, this weekend was just like that Candid Camera episode. Only, with masks. At the park, at my kids’ bus stop, I’d roll up—much of the time, without a mask—and I’d wait. I was following the new CDC guidelines, released  last week, that say vaccinated people can go without masks, almost everywhere, especially outside. But one by one, the people all around me would stay masked. Or they’d find a mask and put it on. And I’d wonder, hold it, am I the asshole?

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I called up Megan Ranney, an ER doctor who teaches at Brown University, to see if she could help me figure this out. On Monday’s episode of What Next, we spoke about what these new guidelines ­­really mean and whether the guidance is premature. Our conversation has been edited and condensed for clarity.

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Mary Harris: Can we go back in time? Because I think part of the reason that people may have struggled with this new guidance from the CDC is that it’s been such a quick turnaround. I remember back in March, Rochelle Walensky was talking about impending doom from COVID, like a creeping sense of dread.

Megan Ranney: The difference between March and today is the rate of vaccine delivery. We have done a better than expected job in the U.S. of getting vaccines in arms, and our case rates have dropped accordingly. And the amazing thing is: These vaccines have proven, in some ways, more effective than we had hoped. They’ve actually worked just as well as they did during the studies. And they’ve seemed to maintain efficacy against most of these variants. And I think that’s the reason for the shift in the tone that you’ve heard, not just from the CDC, but also for most of us in public health. It’s that we’ve seen the vaccines get into arms. And as people get vaccinated, those numbers are just dropping so quickly. It’s marvelous. But the question is: Are we over that hump where this is the part of the pandemic where we can take all our masks off? Because masks, if worn correctly and it’s a good mask, are really just about as effective as some vaccines are. The J&J vaccine and universal masking have about equivalent efficacy. Only in retrospect will we know whether this was the right choice at this time.

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Can we lay out exactly what the new rules and guidelines say and what they don’t?

It is really important to be clear that this is only for people who are fully vaccinated, meaning more than two weeks after your second shot, if it’s Moderna or Pfizer, or two weeks after your single shot, if it’s Johnson & Johnson. And it says that for those folks, you don’t have to wear a mask just about ever, except in health care facilities, in congregate care settings like jails or shelters, or on public transport.

One of the things I tell folks is that they are not obligated to take their mask off. Just because the CDC says it’s safe for most vaccinated people, that doesn’t mean you’re forced to take the mask off. So if you want to keep your mask on, you can. And Mary, I’m going to keep my mask on in public indoor settings for now until vaccination rates go higher.

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But here’s the other side: We also have to manage that anxiety of getting back toward normal. Yes, we have all been staying home and wearing masks for the past year. But the truth is these vaccines are excellent, and we are going to move back toward what life used to look like. And it is OK to take those masks off if you are fully vaccinated outside or indoors, if you’re with other fully vaccinated people, with a trusted group, or if rates are really low in your community at that point.

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You said that after this guidance, you’re not going to change much in your own life. And I wonder if you can talk a little bit about why.

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So first, obviously, I work in the ER, so I’m wearing a mask when I’m at work no matter what. Second, not everyone in my family is vaccinated yet. I also have parents who are high risk. I feel like I’ve made it this far, and although the vaccines are stellar, they’re not 100 percent. I don’t want to take that small risk of catching COVID at work or out at a social gathering when I’ve been lucky so far.

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The last part is I live in Rhode Island, which has been tremendously successful at getting vaccines in arms. But even in my state, over half of adults are not fully vaccinated yet. The rate of vaccine uptake is just not high enough yet for me to trust that I’m not going to be exposed to more than one person with COVID. I’m going to wait a little bit longer. I’m expecting I’ll start taking masks off indoors probably in the summer.

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Can I do a lightning round with you about what your choices might look like right now? Like, OK, you’re going for a walk in an urban environment, you’re going to be passing a bunch of people. Mask or no mask?

No mask. Outdoors is tremendously safe.

You’re having dinner outdoors or a picnic in the park, it’s crowded park, lots of people, dogs, you can’t really control who’s who. Mask or no mask?

No mask. Outdoors is lovely.

Kids birthday party. So lots of people who are not vaccinated. Outdoors, indoors, either one. Masks or no masks?

Outdoors kids birthday party: no masks.

Should the kids be in masks?

It depends on how many kids are there. But I’ll be honest, I don’t make my kids wear masks for outdoor playdates.

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OK, so let’s say you’re going to a mall, you’re going to go shopping. Are you wearing a mask?

For now, I’m still masking.

Transportation. Let’s say you are going on a trip, maybe you’re renting a rental car, maybe you’re taking a train, maybe you’re taking a plane. What are the rules for those kinds of situations?

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Any public transportation right now, we should all be masked. But if you’re in a rental car, if it’s me and my family, no mask. If it’s me and some friends who are vaccinated, no mask.

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One thing the CDC didn’t do before announcing these guidelines was apparently warn the states they were going to do this. And you could see that in the way local health officials responded to the news. The mayor in Kansas City, Missouri, apparently went from saying he wouldn’t change his mask mandate to saying he’d consider changing it to saying he’d get rid of it in the space of seven hours, which is just mind-boggling. Do you think the CDC acting so quickly and decisively without warning people was a mistake?

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I think a big part of public health is communication, right? There’s the science, and then there’s the behavioral side. It would have been lovely for the CDC to communicate about the science and to give folks some lead time. I think an ideal world would have been to clarify the science around vaccinated people, but to give people some clear metrics around when it was safe for communities, because there’s a difference between a risk to an individual and to a community. So to provide some metrics for communities around that mask mandate lifting. Because remember, mayors and business leaders are not public health professionals. They’re saying, well, the CDC says it’s safe. So I guess I can’t require masks anymore. And I don’t know that that was fair to some of our non–public health leaders.

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It was interesting to me to see how quickly after these guidelines came out things began to change, especially when it came to the private sector. Walmart, Costco, Publix , Starbucks, all of them. It was like flipping a light switch. They went from mask requirements to no masks, but they didn’t say they would be checking vaccine cards at the door or anything. When you heard that, did you think, Oh, that was fast?

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That was exactly my reaction. I think the businesses were left without a leg to stand on. Once the CDC says everyone who’s vaccinated can take a mask off, businesses don’t really have a choice. They’re getting a lot of pressure from clients and customers to allow them to go maskless. Most of that pressure is from folks who are unvaccinated, but it makes it really tough for them to maintain the mandate when there’s no longer this sense of community or collective responsibility.

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What does having kids mean for mask wearing decision-making? Do you think parents should still be modeling mask wearing for their kids in certain settings where they may not need a mask anymore because maybe they’re vaccinated?

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Absolutely. As a parent, I have to show my kids how to behave. And if I’m telling them to do something, I have to do the same thing. So if I want my kids to continue to mask in indoor public settings, which is the appropriate thing right now, when rates of COVID are not yet close to zero, I need to mask. Now the risk to kids—the younger you get, the lower your risk of getting severely ill—but it’s not, again, a zero risk, and our 12- to 15-year-olds have just become eligible for vaccines. It is still critically important for our kids to mask at school and at other indoor settings right now until the rates drop. This is the really difficult thing: It is not a black-and-white distinction. There will be a point over the next couple of months where I and others will start to say it’s OK for kids to be maskless indoors if COVID rates in the community are low and vaccine rates are high, because the kids are going to be protected by the rest of us. But we’re not there yet.

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Let’s talk about the unvaccinated and how this new guidance may or may not affect them. I think the worry is that this guidance becomes a get-out-of-mask-free card for unvaccinated people, since we can never know someone’s vaccination status, at least not easily. What do you say about that?

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I think that’s totally true. My question is: How much were those folks masking to begin with? And then the other part is: They are mostly putting themselves at risk. The part that bums me out is that they’re potentially putting the rest of us at risk as well, again, because our vaccination rates aren’t high enough yet and they’re going to create little surges in parts of the country where vaccine rates are still low by going unmasked.

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Should we be asking people to show, like, their vaccine card at the door if we’re letting them into an indoor public space?

Honestly, I would love that. People have said to me, “Will you take a cruise, or will you go to a movie theater without a mask?” If there were a way to ensure that everyone there were vaccinated, I would be thrilled. I would even be willing to pay a little extra for something if I knew that everyone were vaccinated around me.

The real question is whether this guidance becomes an incentive for some people to get vaccinated or an incentive for them to lie. And I don’t know if we know an answer to that. I don’t know if there’s previous research about how people think of themselves in these kinds of situations and think of others and how this might go.

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Back when we first mandated universal masking, one of the concerns was that people would take other risks because they thought they were protected by masks. And that turned out to totally not be true. And in fact, there’s a lot of research showing that when you get people to take one risk reduction behavior, they actually tend to increase the full suite of risk reduction behaviors. There’s also research talking about community good—that sense of collectivism from a universal or near universal strategy. So even if you’re in an area where mask mandates have not been in place, the fact that Walmart mandated masks, you knew that when you were in there, it was an expectation that everyone would be masked.

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It’s tough to imagine that part of the reason for making this announcement now instead of a month from now was not also because they want to try to motivate people to get vaccinated, that they think that by telling people that you can take your mask off if you’re vaccinated, that it will drive more people to get the vaccine. I’m just not sure that’s going to be true.

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So you’re basically telling me the thing that I fear, which is being in a room full of unvaccinated people without masks. Yeah, that’s real.

That’s real. And then the question becomes, how much do you trust the vaccine and how worried are you about a small chance of catching COVID yourself? The science is clear that the vaccines are amazing. And if COVID cases are low in your area, being in a room of unvaccinated people may not be that dangerous because the chance of one of them having COVID is low, the chance of you catching it is low, and you’re probably going to be OK. And this is where that trade-off comes in. If rates of COVID your community are high or if you’re high risk and don’t want to take that small chance of catching COVID yourself, then sadly you are going to continue to need to mask up even if you’re fully vaccinated.

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It feels like a very American decision. It’s interested in getting us to feel better individually and but maybe not collectively.

That’s the struggle of public health in the United States. It is this constant tension between the collectivist and the individualist. And I’ll be honest, the individualist almost always wins.

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I wonder a little bit if this decision was made because we’re at this point where enough people are vaccinated, not for herd immunity, but so that if there’s a spike in COVID cases in an individual area, it’s not going to overwhelm the hospitals in the way that it did last spring or even in the winter. And so that sort of structural issue is relieved a bit. And people are going to make their choices, which sounds a little harsh, but it is a little bit what we do each year with, say, the flu. We offer a shot; you can get it or not. We know that there will be a surge in people going to the hospitals, but we accept it. And we know that it’s at a point where it won’t overwhelm the hospitals.

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That’s exactly right. We have reached the point in the pandemic where as a society, it is not going to overwhelm us anymore. And so, again, it goes back to this individual factor of tough cookies for you if you happen to be someone who’s not been vaccinated or for whom the vaccine hasn’t fully worked. As a society, we’re more or less going to be OK, assuming no new horrible variants. And it’s what we do for a lot of things. We know that motorcycles are riskier than cars, but there’s a lot of folks that choose to ride motorcycles because they’re fun. My ER was full of motorcycle crashes this weekend because it was a gorgeous weekend in Rhode Island and there were a lot of folks out. That’s a risk that we as a society take. We can’t wrap everybody in a bubble forever. And I don’t think anyone expected that or wants that. Again, the question is: Was this the moment to allow folks to go unmasked? And only time will tell, it may turn out to be OK, or it may turn out to have been a little premature.

For more conversations like this, follow What Next on Apple Podcasts or wherever you listen.

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