A Change of Opinion

A Change of Opinion: Public Health Policy on Masks during the 1918 Influenza Epidemic
By Ariel Ludwig, Jessica Brabble, and E. Thomas Ewing

Americans living through Covid-19 have to contend with the reality that public health policies change as conditions evolve. Since the epidemic reached the United States earlier this year, regulations on social distancing, testing, transmission, and masks have changed over time and across jurisdictions. In a polarized political climate, admissions that previous policies were insufficient or incorrect have been weaponized by those seeking to undermine government agencies and tarnish policy makers. While changes may be unsettling for a population seeking clear guidance in uncertain times, we need to recognize that good public health policy-making is based on available evidence and thus must adapt as the context changes.

Recent weeks and months have shown that changes in health guidance produce confusion, anxiety, and even suspicion across much of American society. In the early spring, medical authorities including the CDC and Surgeon General recommended against wearing masks in public, but by early summer, most states had adopted some form of mask requirement, yet substantial differences were evident in enforcement across cities, small towns, and rural communities. The World Health Organization and CDC initially claimed that only droplets could spread the disease, but have now accepted the scientific evidence supporting airborne transmission. While social distancing measures confirmed the importance of avoiding close contact with other people, only more recently has attention focused on monitoring and improving indoor ventilation as an important measure. Guidance on testing issued by federal organizations was withdrawn, revised, or contradicted, often with limited or no input from scientific experts or public health officials.

At a time when the American public urgently needs clear, consistent, and accurate guidance on public health policies, these stunning reversals have prompted considerable dissatisfaction. This criticism fails to acknowledge the importance of adapting health policies as the epidemic develops, research produces new understanding, and the behavior of society produces new imperatives. Choosing and sustaining the correct policies requires constant monitoring, adaption, and engagement--including the likelihood of having to admit that earlier recommendations have to be changed.

Yet Beatty became increasingly “skeptical regarding the efficacy of influenza masks.” By the end of November, Beatty declared that sufficient evidence had been gathered to indicate that mask ordinances were impractical, proper use could not be enforced, and measures to track cases, isolate the sick, and ban public assemblies were more effective. Drawing upon published reports, Beatty cited death rate statistics to show that cities with mask regulations, such as San Francisco and Oakland, actually did worse than cities, such as Los Angeles, St. Louis, Seattle, and Cleveland, which did not require masking. “The mask,” Beatty declared, “is absolutely harmful.” At a meeting with Ogden health officials debating the mask ordinance, Beatty admitted to a “change of opinion,” but he also “qualified” his position by declaring “a perfectly clean, well sterilized mask, which is changed every two hours, is a highly commendable form of prevention” for those in close contact with the public.

Although the Ogden newspaper criticized these “mental somersaults,” Beatty’s record of revisions is actually quite instructive for health authorities and the public in 2020. Policy-makers need to examine evidence of outcomes, evaluate a range of options, recognize the contingency of any measures, be prepared to admit mistakes, and, most importantly, demonstrate a commitment to the well-being of the entire community. In the early stages of the 1918 epidemic, mask requirements were implemented in many cities as an emergency measure to contain the spread of disease. As the number of cases and especially death plateaued and began to decrease, it made sense to lift this requirement. More importantly, many people undermined the effectiveness of masks by taking them off inside, wearing them incorrectly, allowing them to become dirty and thus a source of infection, or refusing to wear a mask as a gesture of defiance. As data about death rates became available, Beatty concluded, the evidentiary basis for mask regulations was increasingly unsustainable. In this sense, Beatty’s “mental somersaults” anticipated the recent observation by Dr. Anthony Fauci about the challenges of making public health policy during an epidemic: “We’ve got to realize that, from day one, you don’t know it all. And you’ve got to be flexible enough to change your recommendations, your guidelines, your policies, depending on the information and the date as it evolves...You’ve just got to be humble enough to realize that we don’t know it all from the get-go and even as we get into it.”

It is perhaps ironic that Dr. Beatty’s initial endorsement of masks, which he subsequently repudiated, has now become a consensus recommendation in American public health. Our review of evidence from 1918 in light of current conditions suggests that the reasons Beatty changed his opinion are actually consistent with recommendations to wear masks. First, wearing masks promotes social distancing, or, as Beatty declared, the urgent need to “avoid the crowd.” Wearing a mask tells those around you that you want them to keep their distance, and you will do the same. Second, wearing a mask should promote better personal hygiene by preventing people from coughing on each other or from touching their faces, thus blocking important routes of transmission. Finally, mask wearing must be combined with other health measures, sustainable, and supported with evidence. As we look ahead to more months of mask mandates, we all need to remember that the purpose of health policy, as Beatty stated emphatically early in the epidemic, “is to SAVE HUMAN LIVES.”