Why lifting mask mandates is so divisive

Implementation science tells us why—and suggests some paths forward

ON FRIDAY, the US Centers for Disease Control and Prevention updated its mask guidance for the first time since July—including for schools, where the debate on whether to mandate them has been highly polarizing. This update follows announcements from governors of states from across the country, who got ahead of the CDC in lifting their mask mandates, including for schools.

The move away from universal indoor masking requirements represents a major policy change in many parts of the country, and has been met with resistance from many physicians, public health experts, and constituents who have long supported strict masking policies, even in regions with high vaccine uptake.

After two years of studying the virus that causes COVID-19 and how to prevent its transmission, why is lifting mask mandates so divisive and contentious? Lifting public health measures is often harder than starting them, and implementation science research provides some insights into why.

Removing any public health intervention, or “deimplementation,” is fraught with challenges. National Institute of Health scientists highlight barriers that make lifting of public health measures hard – fear and anxiety (from the population and scientific advisors); strength and quality of evidence guiding the policy change; consistent support for the policy change from officials and guideline-issuing organizations; and lack of trust in government and public health institutions.

The explosive debate about mask mandates in schools is practically a case study in the collision of all of them, although the CDC has now hopefully made the transition easier for much of the country by effectively endorsing the moves already made by the Baker administration and Department of Elementary and Secondary Education, and alleviating one of those major barriers.

Public health experts (and physicians) have a general bias toward “doing something,”  so it’s no wonder that scientists err on the side of recommending more interventions during a deadly pandemic. Moving away from mitigation measures recommended early on is especially hard when the media and many policy makers have counted every case of COVID-19 and scrutinized every twist of the pandemic for two years. Immunity, although highly protective against severe disease, is not tangible. Masks can be seen and felt – a feature that also contributes to challenges moving away from them.

The evidence behind masking mandates in schools has been low-quality from the start, and guidelines for preventing COVID-19 in schools were based on evidence adapted from other settings, such as hospitals, and guided by the precautionary principle. These approaches were reasonable initially — when there were no vaccines to prevent severe disease, no medications to prevent disease progression, and a more limited understanding of how COVID-19 was transmitted–but need to be re-evaluated in light of the many advancements that have occurred.

Relying on low-quality evidence has several impacts: first, it allows everyone to claim that the evidence is “on their side.” Second, it contributes to a lack of trust in government and public health institutions— known deimplementation barriers.

Public trust is essential for navigating the next phases of the pandemic and for evolving school policy. To these barriers, add a distrustful political climate, locally-driven processes, and social media echo chambers. The state of the discourse, even and especially among scientists on social media, is vitriolic, and in full public view. Scientific opinion that goes against a prevailing narrative is quickly silenced. Real and necessary conversations about mitigation measures, the true risks and benefits of given interventions, and nuanced policy discussions, therefore do not happen.

We don’t know what the long-term impacts of aggressive in-school mitigation policies are – and we won’t for a long time. People have a bias toward focusing on discrete, near-term outcomes and discounting things that might happen long into the future. We can get the results of a rapid COVID test in 15 minutes. Impacts on literacy and education are harder to measure and take longer to manifest. How much risk are we willing to take with our children’s long-term success? How long are we willing to let educational disruptions continue? These conversations need to be had alongside considerations about preventing viral transmission—and the CDC update will allow this to happen.

Meet the Author
Meet the Author
Meet the Author
We commend the CDC for shifting its focus away from cases and toward prevention of severe disease and protection of patients with limited immunity. Scientists can help design prevention strategies, but when goals of mitigation measures are not delineated, there is a lot of room for interpretation about “what the evidence says” and how “the evidence” should inform policy. Lack of clearly defined goals contributed to substantial disagreement – and claims from all sides that theirs was the most evidence-informed approach.

So how should policies continue to evolve? First, we need to consider the changing pandemic context and accept that prevention recommendations that are appropriate for one phase may not be for another. It means focusing on public health interventions that are more sustainable in the long-term than universal masking, like vaccination and sick-leave policies.  It means embracing de-implementation as necessary, rather than seeing it as “giving up.”  We also need to continue to support scientific investigation, so we can develop the most evidence-informed policy—and continue to adapt policy to meet the needs of today.

Westyn Branch-Elliman, an infectious diseases physician, is an associate professor of medicine at Harvard Medical School. Elissa Perkins is an associate professor of emergency medicine and director of emergency medicine infectious disease management at Boston Medical Center/Boston University School of Medicine. Dr. Shira Doron, an infectious disease physician, is hospital epidemiologist at Tufts Medical Center and an associate professor at Tufts University School of Medicine.