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