Social dramas

Droplet precautions became ritualised

The official droplet-but-not-airborne narrative materialised as artefacts (e.g. posters, disinfectant dispensers, 2-metre distancing markers) and social practices (actions accepted and expected in particular contexts).55 Droplet-directed practices became ubiquitous among individuals, who washed hands and forearms assiduously for 20 seconds, quarantined and disinfected their post, and stayed a measured distance apart, and also in institutions, who installed and policed the various artefacts and practices.
These rituals of purification56 powerfully reinforced the official narrative. “Clean” and “contaminated” came to be demarcated in terms of how recently and thoroughly hands had been sanitised and how far a droplet was assumed to travel (Table 1, column a). They also served to downplay or obscure the narrative of aerosol transmission—which demarcated “clean” and “contaminated” in terms of air purity, with practices oriented to controlling indoor crowding and time spent indoors, ventilating or filtering air, and optimising quality and fit of masks (Table 1, column b). These material and enacted features of policy discourse served to further silence the “Covid-is-airborne” narrative.

Care home residents died in their thousands

On 23rd March 2020, with up to 500,000 deaths and an overwhelmed National Health Service predicted,57 the UK Prime Minister announced a national lockdown (“stay at home”, “protect the NHS”). Hospitals had switched into urgent discharge mode from 19th March, sending patients back to care homes without routine pre-discharge testing. Between March and June 2020, 18,104 deaths involving Covid-19 and 11,169 additional deaths above the 5-year UK average occurred in care home residents.58
Amnesty International depicted the UK’s care home crisis as a gross breach of human rights in which thousands of vulnerable people had been treated as expendable.59 The crisis was also largely avoidable. Public Health England’s guidance for care homes had emphasised a situationally-airborne narrative.60 Since aerosol-generating procedures were rarely undertaken in care homes, these settings had been considered low priority for personal protective equipment.
Under-emphasis of the importance of ventilation and no routine use of masks are likely to have greatly amplified transmission between infectious residents and care home staff. In Hong Kong, by contrast, surgical masks were mandated for all care home staff by late January 2020 and no excess care home deaths occurred in wave 1.61

Public masking became a libertarian lightning rod

Libertarianism is a political ideology which favours individual choice, freedom and a retreat from state and institutional control.62 Libertarians resist imposed rules and like to “do their own research” rather than trust scientists or government. Uncertainty and conflict about the value and place of public masking allowed libertarian messages and practices to flourish.
At its 4th February 2020 meeting, the Scientific Advisory Group on Emergencies advised masks for symptomatic Covid-19 patients to reduce transmission “if tolerated”.63This group had acknowledged the potential for asymptomatic transmission of SARS-CoV-2 on 28th January 2020,64 but did not make the logical leap to recommend masking asymptomatic people as source control. Indeed, in official meetings between January and April 2020, either public masking was not mentioned or arguments against it—lack of efficacy, harm, wastage–were tabled (see Appendix on bmj.com). Public announcements65 and professional videos66 issued by Public Health England between February and June 2020 presented masking as ineffective and potentially harmful, on the grounds that people might take compensatory risks or self-contaminate when they put on or removed their mask (the “donning” and “doffing” of infection control jargon66). They provided no evidence to support these claims.
The contested efficacy of facemasks in controlling SARS-CoV-2 transmission can be explained in terms of how much of the evidence base one is prepared to consider.67 An influential inside-track narrative appeared to conflate absence of relevant randomised controlled trial evidence with evidence that masking was ineffective.22 Outside-track scientists argued for the precautionary principle, on the grounds that there was—as early as March 2020—indirect and mechanistic evidence (notably, around asymptomatic transmission) and strong theoretical arguments for public masking, and huge potential risks associated with delay.68 69
Mask mandates were finally introduced in England on 15th June 2020 (public transport) and 24th July 2020 (all public places). By that time, public opinion was polarised and many believed it was an ineffective measure.70 71 Whereas most Asian countries had high public compliance with early masking policies and extremely low death rates, many Western countries introduced masking late and had many more deaths, though causal links are complex and confounders many.72
Masking policies in UK, as in US, met with a strong libertarian backlash aligned with populist political leaders, right-wing Christianity, anti-authoritarian social media groups and—latterly—anti-vaccination groups.73-76 In this context, masks came to symbolise pointless restriction of individual freedom, mindless compliance with authoritarian governments, and even blasphemy.77

Healthcare settings became occupational health battlegrounds

As a novel respiratory pathogen, SARS-CoV-2 was initially classified as a High Consequence Infectious Disease (HCID) by the Four Nations Public Health Agencies.78 Consequently, staff caring for suspected or confirmed Covid-19 patients required filtering facepiece [FFP3] respirators or equivalent.79 This reflected guidance from the UK Health Security Agency (previously Public Health England) and Health and Safety Executive on other coronaviruses80 81 and avian influenza,82 and legal requirements for employers to protect their workers against airborne biohazards.83The Health and Safety Executive had concluded in 2008 that surgical masks “should not be used in situations where close exposure to infectious aerosols is likely” .84
However, minutes from the New and Emerging Respiratory Virus Threats Advisory Group in March 2020 reflect growing concern about shortages of respirators and the Department of Health and Social Care’s request for “adapted” guidance that recommended surgical masks in most circumstances.85 The Deputy Chief Medical Officer agreed to meet with the Chair of the Advisory Committee on Dangerous Pathogens,85 whose members: “were unanimous in supporting the declassification of COVID-19 as a HCID” (paragraph 2.11). 85
A letter to UK healthcare organisations dated 28thMarch 2020, sent jointly from NHS England and NHS Improvement, Public Health England and the Academy of Medical Royal Colleges, affirmed that because of rising Covid-19 cases and because “more was understood about the behaviour of the virus and its clinical outcomes” (i.e. in view of the assumed droplet-but-not-airborne narrative),86respirator-grade protection would now be restricted to aerosol-generating procedures.86
The number of UK health and care workers infected with SARS-CoV-2 at work is not officially documented. Press reports claim that by mid 2021, around 1500 had died of Covid-1987 and 120,000 had developed long covid (some of whom remained on long-term sick leave).88 In April 2020, excess deaths were noted amongst healthcare staff (especially men and minority ethnic groups) working outside intensive care units,89 and this impression was confirmed in subsequent academic publications.90 91 In early 2021, the British Medical Association92 and the Royal College of Nursing93 94 demanded respirator-grade protection for all staff working with Covid-19 patients.
The latest guidance from the UK Health Security Agency continues to promote a situationally-airborne narrative and restrict respirator use to aerosol-generating procedures.95 Its guidance cites contradictory sources—from the World Health Organisation (which reserves respirator-grade protection for aerosol-generating procedures),52 and US Centers for Disease Control and Prevention (which recommends respirator-grade protection during all Covid-19 patient care).96 There remains wide variation in infection control policies in different NHS trusts (perhaps because some interpret the guidance as mandatory); those which provide respirator-grade protection appear to have significantly lower nosocomial infection rates for Covid-19.97