Relaxing Mask Mandates in New Jersey A Tale of Two Universities

Abstract

Photo by Mika Baumeister on Unsplash

INTRODUCTION

In March of 2022, New Jersey Governor Phil Murphy announced that the state would no longer mandate face masks for students, staff, and visitors at schools and childcare centers. Two-thirds of New Jersey residents already supported this decision.^[1] Soon after, Princeton University led the way in learning to live with the virus by making the use of masks optional in most situations. At a time when vaccination rates were already high and Omicron hospitalization rates were falling, the decision to relax mask mandates was the right call. 

Yet, Rutgers University has extended its mask mandate for the rest of the academic year, with no stated endpoint. In a university-wide email, Executive Vice President and Chief Operating Officer Antonio Calcado announced:

The university has been clear that the science and data would guide our path forward with respect to the health and safety of our community… Use of appropriate face coverings will still be required in all teaching spaces (classrooms, lecture halls, seminar rooms, etc.), teaching labs, computer labs, buses, libraries, and clinical facilities.^[2]

Despite the university’s purported commitment to follow “the science and data,” there has been a noticeable lack of transparency regarding the scientific rationale and official endpoint for this extension of the mask mandate.

Given the same set of scientific data available, these neighboring universities came to opposite conclusions on the need for continued mask mandates. Notably, the Rutgers mask mandate continues to require students to mask in libraries but not in crowded cafeterias. These discrepancies have led to understandable frustration among members of the Rutgers community. In response, the Rutgers student newspaper objects to “the sense of optics” and “the lack of clear communication,” resulting in “confusion,” arguing that the university administration “needs to be more transparent” and “must communicate and explain the policy changes more effectively.”^[3] At a time when trust in public health institutions is at an all-time low, Ava Kamb warns that a lack of transparent messaging can reduce public trust even further.^[4] Instead, Kamb argues that public health mandates should use the least restrictive means necessary in order to promote health and civil liberties at the same time.

The ethical question is whether university mask mandates should be relaxed. I argue that the use of face masks by healthy individuals has uncertain benefits, which potential harms may outweigh, and should therefore be voluntary.

ANALYSIS

Rutgers intends “the science and data” to guide its path forward. As such, it is worth revisiting the controversial science behind mask mandates. From 2019 to 2020, systematic reviews by the World Health Organization (WHO) and Cochrane Acute Respiratory Infections concluded that the use of face masks by healthy individuals in the community lacks effectiveness in reducing viral transmission based on moderate-quality evidence.^[5] Neither study concerned COVID-19 specifically. Since then, the only two randomized controlled trials of face masks published during the pandemic found little to no benefit.^[6] Yet, the Centers for Disease Control and Prevention (CDC) cite many observational and modeling studies (based on empirical assumptions) which suggest that community masking is beneficial.^[7] These studies support a larger benefit associated with masking, but they use less reliable research methods. Based on these non-randomized data and mechanistic plausibility, WHO’s current position is also supportive of community masking recommendations. But without high-quality evidence, it is difficult to justify a requirement rather than a recommendation.

It may be useful to draw an ethical distinction between a recommendation and a mandate in public health. A public health recommendation does not generally undermine individual autonomy because individuals have the choice to follow the recommendation. I argue that recommendations may be justified by a lower standard of proof or a lesser expected benefit precisely because they do not violate individual autonomy. On the other hand, a public health mandate demands compliance using the threat of penalty. To ethically justify an infringement of autonomy, strong evidence that demonstrates a significant health benefit should support a public health mandate. While the recommendation to use masks in accordance with personal preference may be a reasonable precaution—particularly for vulnerable individuals—the higher standards of evidence and benefit that would ethically justify mask mandates have not been met.

Notwithstanding, one might argue the precautionary principle justifies mask mandates. For example, Chinese CDC Director-General George Gao, medical researcher Trisha Greenhalgh, and others espouse such a view.^[8] The precautionary principle holds that it is better to be safe than sorry. In the context of COVID-19, the principle has been used to advocate for public health measures which lack high-quality evidence. Accordingly, it might be thought that it is safer to implement potentially ineffective mask mandates than to risk forgoing a lifesaving benefit. Yet, the precautionary principle is an ill-defined concept that is philosophically problematic. Health economist Jay Bhattacharya and epidemiologist Sunetra Gupta argue that the precautionary principle cuts both ways because a public health mandate without high-quality evidence has both potential benefits and potential harms.^[9] If the precautionary principle can justify implementing mask mandates due to the risk of forgoing possible benefit, then it might also be able to justify not implementing mask mandates due to the risk of potential harm caused by the intervention.

It is commonly thought that there is little to lose from the use of face masks, but this is not necessarily true. According to WHO, CDC, and the European Centre for Disease Prevention and Control (ECDC), the harms of face masks may include headaches, difficulty breathing, skin lesions, difficulty communicating, a false sense of security, environmental pollution, impaired learning, delayed psychosocial development, and disadvantages for individuals with cognitive or mental disorders.^[10] These include both potential and observed harms drawn from the scientific literature. Yet, the negative side effects of masks remain significantly under-investigated. For example, there is emerging mechanistic evidence that prolonged mask use or reuse increases both inhaled and environmental microplastics, the long-term effects of which are unknown.^[11] The harms related to communication, learning, and psychosocial development are particularly problematic for educational institutions, whose mission is to promote these very things. It is, therefore, possible that masks have done more harm than good.

While many observational studies and models support the potential benefits of masks, some interpret these studies to mean that masks clearly work. However, the limited body of randomized data paints a less optimistic picture and cannot be used to rule out an increase in infection from masks.^[12] Other types of studies, less reliable research methods, do rule this out and support masking. Bhattacharya and Gupta would argue that it is safer to encourage voluntary, evidence-based interventions than to foist these potential harms upon individuals for the sake of uncertain benefits.

It remains unclear whether and to what extent the use of face masks by healthy individuals in the community influenced COVID-19 mortality. However, it is clear to me that community masking does not meet the higher standard of evidence necessary to justify a mandate and that mask use is associated with potential harm. The already tenuous case for masks continues to weaken with a mixed body of evidence, the availability of effective pharmaceuticals, and widespread natural immunity to COVID-19. If public health should aim for the least restrictive means necessary to promote health while respecting civil liberties, then the extension of burdensome mask mandates which lack high-quality evidence is ethically problematic.

CONCLUSION

Given the current state of COVID-19, a university mask mandate for a low-risk population with high levels of immunity is not justified. In times of fear and uncertainty, higher education institutions ought to make reasoned policy decisions guided by “the science and data.” It would seem that, of the universities that mandated masks, Princeton has emerged as a national leader in mask policy while Rutgers lags behind. Schools across the nation should take note.

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[1] Rutgers University Eagleton Institute of Politics. Two-thirds of New Jerseyans agree with lifting school mask mandate, most comfortable returning to normal; half think NJ has done “just right” on pandemic. Accessed May 14, 2022. https://eagletonpoll.rutgers.edu/wp-content/uploads/2022/03/Rutgers-Eagleton-Poll-COVID-March-7-2022.pdf

[2] Calcado AM. Return to Campus Update – January 31, 2022. Accessed May 14, 2022. https://coronavirus.rutgers.edu/changes-related-to-covid-19-protocols

[3] The Daily Targum. Rutgers’ new mask policies are more than confusing. Accessed May 14, 2022. https://dailytargum.com/article/2022/04/editorial-rutgers-new-mask-policies-are-more-than-confusing

[4] Kamb A. The false choice between public health and civil liberties. Voices in Bioethics 2020;6. doi:10.7916/vib.v6i.6297.

[5] World Health Organization Global Influenza Programme. Non-pharmaceutical public health measures for mitigating the risk and impact of epidemic and pandemic influenza. Geneva: World Health Organization; 2019; Jefferson T, Del Mar CB, Dooley L, et al. Physical interventions to interrupt or reduce the spread of respiratory viruses. Cochrane Database of Systematic Reviews 2020;11(CD006207). doi:10.1002/14651858.CD006207.pub5.

[6] Abaluck J, Kwong LH, Styczynski A, et al. Impact of community masking on COVID-19: A cluster-randomized trial in Bangladesh. Science 2022;375(6577):eabi9069. doi:10.1126/science.abi9069. (intervention reduced symptomatic seroprevalence by 9.5%; 95% confidence interval = [0.82, 1.00].); Bundgaard H, Bundgaard JS, Raaschou-Pedersen DET, et al. Effectiveness of adding a mask recommendation to other public health measures to prevent SARS-CoV-2 infection in Danish mask wearers: A randomized controlled trial. Ann Intern Med 2021;174(3):335-343. doi:10.7326/M20-6817. (trial was conducted in a setting where mask wearing was uncommon and the findings were inconclusive; 95% confidence interval = [0.54, 1.23].)

[7] U.S. Centers for Disease Control and Prevention. Science Brief: Community Use of Masks to Control the Spread of SARS-CoV-2. Accessed May 14, 2022. https://www.cdc.gov/coronavirus/2019-ncov/science/science-briefs/masking-science-sars-cov2.html

[8] Zimmerman A. The precautionary principle in mask-wearing: When waiting for explicit scientific evidence is unwise. Voices in Bioethics 2020;6. doi:10.7916/vib.v6i.5896. (supporting the use of masks early in the pandemic arguing that the harms of masking in the short term were unlikely to be severe or to outweigh the benefits.); Greenhalgh T, Schmid MB, Czypionka T, et al. Face masks for the public during the COVID-19 crisis. BMJ 2020;369:m1435. doi:10.1136/bmj.m1435.

[9] Bhattacharya J. On the Catastrophic Misapplication of the Precautionary Principle. Accessed May 14, 2022. https://collateralglobal.org/article/misapplication-of-the-precautionary-principle; Gupta S. A Betrayal of the Precautionary Principle. Accessed May 14, 2022. https://collateralglobal.org/article/a-betrayal-of-the-precautionary-principle

[10] World Health Organization. Mask use in the context of COVID-19: Interim guidance, 1 December 2020. Accessed May 14, 2022. https://apps.who.int/iris/handle/10665/337199; U.S. Centers for Disease Control and Prevention; European Centre for Disease Prevention and Control. Using face masks in the community: First update - Effectiveness in reducing transmission of COVID-19. Accessed May 14, 2022. https://www.ecdc.europa.eu/sites/default/files/documents/covid-19-face-masks-community-first-update.pdf

[11] Li L, Zhao X, Li Z, et al. COVID-19: Performance study of microplastic inhalation risk posed by wearing masks. J Hazard Mater 2021;411:124955. doi:10.1016/j.jhazmat.2020.124955; Ma J, Chen F, Xu H, et al. Face masks as a source of nanoplastics and microplastics in the environment: Quantification, characterization, and potential for bioaccumulation. Environ Pollut 2021;288:117748. doi:10.1016/j.envpol.2021.117748; Chen X, Chen X, Liu Q, et al. Used disposable face masks are significant sources of microplastics to environment. Environ Pollut 2021;285:117485. doi:10.1016/j.envpol.2021.117485.

[12] Bundgaard et al. (inconclusive with a 95% confidence interval = [0.54, 1.23]).