The medical nightmare that is uncontrolled coronavirus spread has afflicted Americans with another painful condition: economic paralysis. But Japan, despite sharing a maritime border with China and nearly one million tourists in January 2020, has so far managed to spare its 127 million citizens the medical and financial disaster of COVID-19. With about ten geographically isolated “hotspots” across Japan, there have been fewer COVID-19 deaths in that nation in a three-month period than among the 400,000 people of New Orleans, Louisiana, in the past six weeks. Japan has not been immune from economic damage, which is global. Prime Minister Shinzo Abe, moreover, recently voiced concern about a possible explosion in outbreaks. But the country has, for now, managed to keep the growth in cases and deaths modest while keeping much of its economy open.
What are the lessons? The 1918 Spanish Flu pandemic took the lives of nearly 500,000 Japanese. (For perspective, the combined death toll after the bombings of Hiroshima and Nagasaki was 200,000.) Since then, a phenomenon began to emerge: “mask culture.” The wearing of cloth or paper “sickness masks” while healthy and in public has become such a standard practice in Japan that in average years, the nation manufactures 4.3 billion face masks for personal use. The typical Japanese citizen goes through 43 masks per year.
Initially a personal public health decision, daily mask wearing became a social etiquette standard and then a fashion accessory. Within the past several years, “sickness masks” have morphed into a trendsetting statement worn by celebrities and fashionistas. Daily public use is ubiquitous.
Articles are written about the season’s most popular patterns. Magazines inform which color mask makes a woman more attractive. There are masks marketed to men, scented versions and even a model that purports to highlight a Japanese standard of beauty —a smaller-appearing face. The latest Japanese mask trend is the Bi Fitto Masukuru, or “Be Fit Mask.” Cut to contour the jawline, it provides a closer fit than the typical rectangular-shaped mask. Smaller gaps provide less room for respiratory particles to escape.
Masks matter because COVID-19 spreads through droplets. The primary way a healthy person is exposed is by coming into physical contact with viral particles contained in the saliva or respiratory secretions of a person with the virus — including one without symptoms. Particles are released when someone infected sneezes, clears his or her throat, laughs, eats or speaks. Droplet spread is not the same as aerosol spread, and evidence suggests that, unlike measles, COVID-19 viral particles do not remain airborne for long enough to create a “cloud” of infectious gas. (The risk of aerosol spread is high mostly for medical professionals, who may come in prolonged close contact with infected patients during procedures.)
Not all masks are as fashionable as the Bi Fitto Masukuru. Different kinds differ in efficacy. The gold standard is the “N95” respirator, whose name derives from testing that proves it filters out at least 95 percent of small particles — including viruses — when carefully fitted to the wearer. Next are surgical masks, typically made of rectangular, pleated nonwoven fabric that loosely conforms to the face without a tight seal. They are meant to provide a physical barrier between the wearer and larger particles in the environment, but are not as reliable as a fitted N95. Finally, there are simple cloth masks. These are not an effective barrier to virus particles, though there is some research suggesting that a homemade mask with a double-layer of cloth and a nonwoven filter in between may equal or exceed the effectiveness of the surgical mask.
In the U.S., across Europe, and among Western public-health authorities, the relentless mantra has been to wash your hands. That’s an excellent part of hygiene, preventing viral transmission from droplets on surfaces to hands that then touch the face, nose and mouth. But hand washing does not prevent person-to-person droplet spread: the spread that will occur when quarantines are lifted and a financially desperate workforce returns to a more normal world, the spread that could lead to a “second bounce” in infections. The visible success Japan, South Korea, Singapore, and other East Asian countries have had in keeping the virus under control should prompt many in the West to revisit their mask-skeptical stance. The new mantra should take into account that masks and hand washing, taken together, have been shown to reduce the transmission of disease.
For healthy people, young people, and essential workers to really make a difference in the spread of this virus to the entire community — including those at high risk who remain at home when the world normalizes — they should consider the Japanese cultural norm of mask-wearing in public. Masks worn in public by healthy people are not to stop the wearer from contracting the virus. They work by limiting the exposure of nearby people to the virus potentially contained within an asymptomatic mask-wearer’s cough or sneeze.
Unfortunately, the adoption of such a radical cultural departure is normally slow. Right now, many of my physician and nurse colleagues in California hospitals are being told by misguided administrators NOT to wear masks outside of patient rooms because “it scares the other patients.” All the while, the spread continues.
Perhaps the Social Influencers of the 21st century could drive this shift from #WashYourHands to #WearYourMask. Celebrity “mask-wearing challenges” might appear on Twitter and Facebook, offering a fad that is lifesaving as well as attention-generating. Fashion designers could offer “spring mask collections” using cutting-edge couture to cut viral transmission. The NHL, NBA, and other sports leagues know more about merchandising than almost anyone in the marketing world; put athletes in team logo masks, and fans will follow.
Eventually, Americans will go back to work. When they do, let’s hope they’re wearing masks.