On April 29 2020, a post titled “Wear Your Mask: The Urine Test” appeared on r/funny (and soon r/all), aiming to explain the purpose of masks during the coronavirus pandemic to pants in the presence of a person uncontrollably urinating everywhere:
The above meme was not the first analogy-based attempt to spread on social media as a way for users to encourage COVID-19 mitigation and suppression:
Coronavirus, Masks, and Peeing All Over the Place
At the top, a title read “WHY YOU SHOULD WEAR FACEMASKS[,] LET ME TRY AND MAKE [THIS] SIMPLE FOR YOU,” and “THE URINE TEST.” Underneath that were three small illustrations: one of a person projectile-urinating onto another person, the second showing the urinated-on person wearing pants, and the third depicting both parties (the one urinating and the one in spraying distance) wearing pants.
To the right of each was a thumbs up or thumbs down image, and text reading:
- [Thumbs down] If we all run around naked and someone pees on you, you get wet right away;
- [Thumbs up] If you are wearing pants, some pee will get through, but not as much, so you are better protected;
- [Thumbs up twice] If the guy who pees also is wearing pants, the pee stays with him and you do not get wet.
Although it wasn’t spelled out directly, the reference to masks and why people ought to wear them in public during an ongoing pandemic was fairly clear.
This Mask Analogy
The meme was in effect claiming:
- [Thumbs down] If we all run around [without masks] and someone [is infectious near] you, you [may get exposed to the COVID-19 virus] right away;
- [Thumbs up] If you are wearing [a mask], some [infectious droplets of aerosolized viral matter] will get through, but not as much, so you are better protected;
- [Thumbs up twice] If the guy who [can spread SARS-CoV-2] also is wearing [a mask], the [virus] with him and you do not get [exposed to that person’s infectious disease].
And much like several other common memes of the day about the purpose and efficacy of facemasks when it came to the spread of COVID-19, the meme more broadly claimed:
- [Thumbs down] If no one wears masks, people who are infected with SARS-CoV-2 and capable of spreading it will infect others unchecked;
- [Thumbs up] If people who are not infected wear masks, they are partly exposed to the spread of the virus which causes COVID-19, but likelihood of transmission is lower;
- [Thumbs up twice] If the guy who is infectious wears a mask [also], uninfected members of the public are twice protected (via their mask and the other person’s mask) and they are far less likely to contract the novel coronavirus in the community.
How Public Health Shot Itself in the Foot on the Topic of COVID-19 and Masks
As we described on several previous pages, the role of masks as the coronavirus outbreak evolved into a pandemic has been confusing to the public, to say the least.
On March 20 2020, we examined then-novel initiatives aimed at sewing large quantities of homemade masks for healthcare workers facing personal protective equipment (PPE) shortages:
Around that time, we learned that the Centers for Disease Control and Prevention had relaxed standards for PPE and COVID-19; previously, the public had been advised masks were not helpful and ought to either be avoided or reserved solely for healthcare workers.
By March 31 2020, public health authorities began recommending the general public wear masks — the same general public that had been cautioned less than one month earlier to avoid masks because they were of no use:
Those directives sowed confusion and created a situation in which disinformation thrived, particularly since the United States Surgeon General essentially forbade their use in a series of adamant tweets:
Just a few days before [on February 29 2020], Surgeon General Jerome Adams told Americans to “Seriously … STOP BUYING MASKS” on Twitter, claiming they are “NOT effective” in preventing the transmission of COVID-19 among members of the general public. Adams instead advised Americans to rely on hand-washing and staying home when sick[.]
Rapidly changing standards both in and outside healthcare settings ensured the change in directive (from “STOP BUYING MASKS” to “wear a mask”) led to impeded or limited compliance with the recommendations. However, evidence did support the wearing of masks as a partial measure to mitigate (but not completely stop) the spread of SARS-CoV-2:
Nevertheless, masks clearly do work to some degree to reduce the transmission of aerosolized pathogens. A May 2013 study in the Journal of Hospital Infection was unable to say precisely to which degree face masks helped, but concluded “they are to some extent protective.” That research noted a number of variables, both in the structure of masks available in and outside clinical settings as well as inconsistency in their usage …
… Although it is true public health initially discouraged general COVID-19 pandemic face mask usage, those warnings appeared to be predicated largely on averting shortages, which continued to be an issue as of late March 2020. That said, coronavirus masks do afford protection, and a number do-it-yourself face mask tutorials were available. At the very least, a secured piece of fabric covering your nose and mouth offers slightly better coronavirus protection than no mask at all.
Essentially, the recommendations earlier in the outbreak of COVID-19 appeared to be an effort to ensure that healthcare professionals would have access to sufficient PPE. When the spread of the virus approached pandemic levels, public health officials were faced with a poorly aged initial directive.
Ongoing Mask Confusion and the Spread of Misinformation
Given that the public was initially told that masks would necessarily not help mitigate the community spread of the COVID-19 virus and that those directives shifted dramatically over the course of a month, residual confusion existed about the relevance of masks as a safety measure.
Healthcare workers, for whom masks were initially reserved, are aware of how masks can and cannot prevent the spread of infectious disease. But for the general public, there was no real centralized resource for regular people to figure out why and how to use masks to prevent the spread.
Information (and disinformation) circulated in a scattershot fashion — with news articles here and there, circulating tutorials, and occasional explanations at press conferences. One controversial but well-explained piece of information came from a Nashville, Tennessee press conference in early April 2020. During that briefing to the public, the president of Meharry Medical College, Dr. James E.K. Hildreth Sr., provided several directives for a public just beginning to work the use of fabric and cloth masks into their daily routines:
Hildreth famously advised the use of microwaves for sterilization when he spoke — but the contents of his overall remarks emphasized the overall goal in the use of masks by the general public to combat community spread.
Hildreth first addressed the national shortage of PPE, and the need to reserve commercial masks for those on the frontlines. He indicated that consequently, members of the public “have resorted” to the use of homemade masks,” encouraged practices to ensure everyday citizens could safely use fabric masks, and emphasized the risk that proper use of masks could result in masks being contaminated (while having protected the wearer from some aerosolized viral vectors):
There’s a national urgency — and I’m gonna repeat this — that the PPE must be reserved for healthcare providers and those on the front line. So many people have resorted to making homemade masks out of bandanas and other kinds of materials … there are a couple of things you really need to know if you’re doing this:
If the mask has served its purpose, there’s every possibility it’s contaminated on the outer surface. What that means is that you should do two things: wash your hands when you take it off, and sterilize it or sanitize it if you’re gonna use it repeatedly.
If possible, wash it in soap and water. And if it’s made out of cloth or has no metal staples in it, you can do what I do: stick it in a plastic bag, and microwave it for two or three minutes at the highest setting.
Numerous studies show that many, many types of bacteria, fungus, and viruses are killed by microwave radiation. You must make sure that your improvised device is compatible with microwaving, and if it is, stick it in a plastic bag and zap it for two or three minutes at the highest setting.
After providing this information about how masks blocked the spread of some diseases, Hildreth moved on to why masks and other protective measures were implemented. In that important portion, he urged the public not to be “a vector,” and expressed his sadness about situations in which people unwittingly spread the virus to those confined to places like nursing homes.
In that portion, Hildreth’s commentary addressed the third panel of the viral meme — and he essentially explained everyone should wear a mask (“pants”) to avoid “becoming a vector” (or “peeing all over people”):
I want to emphasize as you heard earlier that our best strategy still for controlling the virus is to stay at home. My heart breaks every time I hear a new story about a nursing home where the people have gotten infected.
The virus is not floating in the air … someone delivered the virus to that facility, that’s how it started.
Someone was a vector. Please stay at home — comply with the order to stay at home. Only go out when you absolutely have to, and if you have to go out, please cover your face to avoid becoming a vector.
What Masks Do, and What They Don’t Do
As recommendations rapidly changed, the primary public reaction to the updated guidelines was “Why?” An April 3 2020 TIME article explained:
Should Healthy People Wear Masks to Prevent Coronavirus? The Answer May Be Changing
If you have no symptoms of the coronavirus, should you wear a mask? It’s one of the most-asked questions during this pandemic, and until recently, one of the most easily answered—if you follow the guidance of the U.S. Centers for Disease Control and Prevention. The CDC’s answer, up until April 3 ? No. According to its initial guidelines, outside of health care settings, face masks should only be worn by people who are sick or who are caring for someone who is sick (when the person who is sick can’t wear a mask). A mask helps capture some of an ill person’s cough particles that might otherwise spread to other people …
What has changed recently?
Scientists now know that people who are infected with the new coronavirus can spread it even when they don’t have symptoms. (This was not known in the early days of the current pandemic.) Up to 25% of infected people may not show symptoms, said CDC director Dr. Robert Redfield in a recent NPR interview. They’ve also learned that people who are symptomatic shed the virus up to two days before showing symptoms. “This helps explain how rapidly this virus continues to spread across the country,” Redfield said.
This silent spread also bolsters the case for people in the general population to always wear masks when in public, since anyone could be sick. “Now with the realization that there are individuals who are asymptomatic, and those asymptomatic individuals can spread infection, it’s hard to make the recommendation that only ill individuals wear masks in the community setting for protection, because it’s not clear who is ill and who is not,” says Allison Aiello, a professor of epidemiology at the University of North Carolina at Chapel Hill’s Gillings School of Global Public Health, who has researched the efficacy of masks.
Less than one month later, the evolving knowledge about the novel coronavirus had again shifted as of April 30 2020 — and the number of asymptomatic spreaders was possibly as high as 50 percent:
TIME‘s article appeared on the same day the CDC last reviewed a page of recommendations for face masks and community spread of COVID-19. But that information matched the guidance provided by the CDC:
Recommendation Regarding the Use of Cloth Face Coverings, Especially in Areas of Significant Community-Based Transmission
CDC continues to study the spread and effects of the novel coronavirus across the United States. We now know from recent studies that a significant portion of individuals with coronavirus lack symptoms (“asymptomatic”) and that even those who eventually develop symptoms (“pre-symptomatic”) can transmit the virus to others before showing symptoms. This means that the virus can spread between people interacting in close proximity—for example, speaking, coughing, or sneezing—even if those people are not exhibiting symptoms. In light of this new evidence, CDC recommends wearing cloth face coverings in public settings where other social distancing measures are difficult to maintain (e.g., grocery stores and pharmacies) especially in areas of significant community-based transmission.
About a week after those recommendations were provided, LiveScience explained the general gist of how face masks might inhibit the spread of the virus:
[An amount of] leakage in surgical and fabric masks are why public health officials generally don’t believe that wearing a mask prevents anyone from catching a virus that is already floating around in the environment. Airflow follows the path of least resistance, said Rachael Jones, an associate professor of family and preventive medicine at the University of Utah who was not involved in the new research. If viral particles are nearby, they have an easy path around a surgical or fabric mask. And in the case of a fabric mask, wearers may well be wafting in particles small enough to flow right through the fabric.
But what about the other way around? When the wearer of a mask coughs or sneezes, the barrier might be enough to contain a lot of that initial jet of grossness — even if there are gaps in the fabric or around the sides. That’s what the new mask studies aimed to address: Whether surgical or fabric masks did a good job of containing viruses.
That article referenced several studies focused on the efficacy of face masks to prevent viral spreading. Based on the best available information at the time (April 2020), public health directives favored their use for one specific reason:
The results from influenza and seasonal coronaviruses suggest that surgical masks can help keep people with COVID-19 from spreading the virus, [study author Ben Cowling, head of the Division of Epidemiology and Biostatistics at The Hong Kong University] said. SARS-CoV-2 probably behaves similarly to the [earlier known] viruses he and his team studied, he said, and the fact that people can spread the virus before they experience symptoms is an argument for recommending masks for everyone.
As of April 30 2020, a World Health Organization page about coronavirus and masks maintained that people who are “healthy … only need to wear a mask if [they] are taking care of a person with COVID-19.” But as demonstrated repeatedly in the excerpts above, “people who are healthy” are not infrequently asymptomatic spreaders of SARS-CoV-2; that recommendation completely ignores the widespread problem of asymptomatic carriers.
A longer April 6 2020 WHO interim guidance document [PDF] (“Rational use of personal protective equipment for coronavirus disease (COVID-19) and considerations during severe shortages”) weighed the need to preserve PPE for healthcare professionals against its value as a community health measure. Again, that document emphasized the efficacy of masks in symptomatic individuals; we now know that as many as half of those who contracted and may spread the virus which causes COVID-19 have no symptoms at all.
On April 7 2020, Kaiser Health News (KHN) summarized:
Many experts agree that wearing a mask probably won’t keep people from getting the coronavirus, but it might help prevent those with the disease — especially those without symptoms ― from spreading it.
TL;DR: Coronavirus, Face Masks, and the Peeing on People Analogy
An r/funny post titled “Wear Your Mask: The Urine Test” employed an analogy to illustrate the most then-recent understanding of the value of face masks during the COVID-19 pandemic. Its analogy was in line with then-current understanding of how masks might mitigate the spread of novel coronavirus: if no one wore masks the virus would spread more easily; if one infected person without a mask and one uninfected with a mask are in transmission range, the uninfected person has some protection from spread of SARS-CoV-2; when those infected wear masks and if others wear masks, the risk of infection for the uninfected likely drops significantly. While testing numbers remained low and the estimated rate of asymptomatic carriers was between 25 and 50 percent as of late April 2020, it made sense for everyone to wear masks — primarily to prevent spread by those same asymptomatic carriers.