Am I Weird If I Still Wear A Mask?

I am in an increasingly small minority of Americans who still wear face masks in public indoor areas. And I feel increasingly self-conscious when I’m the only person wearing a mask. But should I feel that way?

I realized that something had changed when I attended the annual American College of Chest Physicians meeting in Nashville last week. When I preregistered a few months ago, I had to attest online that I agreed to wear a mask at all times while attending convention events. When got to the meeting last week, the instructions had changed to “masks are recommended”. In the meeting rooms, I kept track – overall, only 5% of attendees wore a mask. I’m used to this percentage of mask-wearers at the grocery store but at the meeting were hundreds of the country’s pulmonary and critical care physicians who are more intimately familiar with the danger and transmissibility of COVID-19 than any other segment of the U.S. population. Except while delivering a lecture, I wore an N-95 mask the entire time but could not help to think “Does everyone think I’m weird?“.

During the first year of the pandemic, I spend endless hours caring for critically ill COVID patients in our ICU. I intubated them, performed bronchoscopy on them, and pronounced them dead. Back then, everyone wore a mask – in the hospital, in the grocery store, in the airport. And masks worked. Unlike the majority of Americans, I have made it this far through the pandemic without getting infected. I was even part of a CDC prospective study of high-risk healthcare workers and had to get serial blood antibody tests to determine if I got infected caring for COVID patients. All of the tests were negative. When vaccines became available in December 2020, I got my first vaccination at 7:00 AM the first day they were available. And I’ve gotten all 3 booster vaccinations in the first week that they were offered. Other than being 64-years-old, I have no risk factors for severe COVID. So, you’d think I’d be ready to go back to life as it used to be, without face masks.

The thing is, I just don’t want to get COVID.

Yes, I realize that the chances of me dying if I get infected are pretty slim. But they are not zero and besides, there are a lot of other unpleasant complications of COVID that I’d just as soon avoid.

Just because you’re vaccinated doesn’t mean COVID can’t kill you

The COVID vaccines we now have are great. But like most vaccines, they are not perfect. Data from the CDC shows that in August 2022, people who had the primary vaccine series plus 2 or more boosters were 12-times less likely to die of COVID than unvaccinated people. But still, 1 out of every 200,000 Americans died of COVID that month despite being fully vaccinated and boosted. To put that in perspective, if you are vaccinated, you are still 1,500-times more likely to die of COVID than to win the Powerball lottery.

A relative commented to me recently that “COVID is no worse than the flu“. Unfortunately, it is actually worse… much worse. In a typical season, about 25,000 Americans die from influenza. In 2021, 463,000 Americans died from COVID. In other words, Americans were 18-times more likely to die of COVID than die of influenza. And that was despite strict social distancing, masking, school closures, and work-from-home initiatives in 2021. This graph shows the annual deaths from influenza (blue) compared to deaths from COVID (gold).

COVID causes assorted badness other than death

Last month, I was surf fishing in North Carolina. I got to talking to a fellow fisherman who as a chiropractor in his late 60’s who had a bout of COVID shortly after returning from a trip to Ireland. He was fully vaccinated and boosted but still felt wiped out for several days. Weeks later, he still could not taste or smell anything. Personally, I like to taste and smell. I like to be able to tell the difference between a pice of unseasoned tofu and a medium-rare lamb chop. I enjoy a Mendocino pinot noir a lot more than a bottle of Two-Buck Chuck. I don’t want to give those things up. A study from JAMA this summer found that 56% of people infected with COVID have some loss of taste and smell at the time of initial infection. Of those affected, 12% still had loss of taste and smell 2 years after infection. Although the newer variants of COVID are less likely to affect taste or smell than the original COVID, 44% of those infected with Delta and 17% of those infected with Omicron had loss of taste and smell.

Patients experiencing long COVID symptoms have now become common in primary care practices. A study from this month’s JAMA looked at 1.2 million people infected with COVID and found that 6.2% of people have long COVID symptoms – persistent fatigue in 3.2%, persistent respiratory symptoms in 3.7%, and cognitive dysfunction in 2.2%. The average duration of long COVID symptoms was 9 months in those who required hospitalization for their COVID infection and 4 months for those who did not require hospitalization. However, 15% of people with long COVID had symptoms lasting more than 1 year. It seems to me that wearing a mask is a small price to pay in order to avoid fatigue, shortness of breath, and brain fog.

Although vaccination greatly reduces the chance of severe COVID requiring hospitalization or ICU care, breakthrough infections are common in vaccinated people as well as those with immunity from previous infection. A study in the New England Journal of Medicine found that breakthrough infections in vaccinated people typically caused fever, muscle aches, loss of taste/smell, and cough. These symptoms lasted more than 14 days in 31% of people and 23% of people had to take off more than 10 days of work due to symptoms. In short, it is no fun to have a breakthrough COVID infection even though you will probably survive it.

The CDC’s COVID dashboard indicates that the number of COVID cases in the U.S. is falling – only 260,000 new infections were reported last week – down from 5.6 million new cases nine months ago during the third week of January 2022. However, the current prevalence numbers underestimate the true number of new covid infections because many people either choose to not be tested or test themselves using over-the-counter COVID home tests. Either way, these cases do not get reported to local public health departments and are thus not included in the CDC’s data. The bottom line is that tens of thousands of Americans are still getting COVID infections every day.

The social pressures to wear masks

The psychology of masking and unmasking is complex and was nicely described in an essay by blogger JTO, PhD. The various psychological concepts that contribute to people disliking masked people when they themselves are not wearing masks include cognitive dissonance, confirmation bias, psychological reactance, and hostile attribution bias. The net effect of these is strong peer pressure to conform when those around you are not wearing masks.

Social psychologist Dr. Wendy Treynor has proposed a theory of peer pressure called “identity shift effect”. According to this hypothesis, a person’s internal harmony is disrupted a person fails to conform to a group standard resulting in a threat of social rejection. In order to eliminate this threat, the person changes their behavior to conform to the group but in doing so, causes internal conflict because that person has now violated their own code of conduct. To eliminate this internal conflict, the person undergoes an “identity shift” and adopts the group’s standards as their own, thereby eliminating internal conflict and restoring internal harmony. The net result is that the person adopts a new attitude.

For example, if you go to a restaurant wearing jeans because you don’t like getting dressed up and everyone else in restaurant is wearing an evening dress or a suit, you will experience a great deal of psychologic disharmony. The next time you go to the restaurant, you wear a dress or a suit in order to avoid the disharmonious feelings, even though in the past, you didn’t like wearing formal attire.

As human beings, we strive to be accepted by groups of other people. Even non-conformists are often trying to conform to the behavior of other non-conformists to prove that they are just as much of a non-conformist as the other non-conformists.

When you wear a face mask in a store full of unmasked customers or in a church full of unmasked parishioners, you start thinking: “Do they think I’m weak?” or “Do they think I’m a coward?” or “Do they think I’m the one who is contagious?” Fortunately, wearing a mask is not as much of a violation of social norms as wearing a MAGA hat to an ACLU convention or wearing a Cincinnati Bengals jersey in a Pittsburgh sports bar. But nevertheless, there is increasing peer pressure to take one’s mask off.

The advantage of being old

One of the wonderful things that happens when you retire is that you now have the luxury of doing what you want to do rather than what everyone else is doing. Even so, I find myself sometimes apologizing for wearing a mask when no one else is. I’ll sometimes offer up excuses such as “Sorry, I worry too much because I’m a senior citizen” or “I’m going to visit my pregnant daughter and don’t want to risk exposing her“. Most people who I pass in a store or airport just think I’m weird. But I can live with that because I plan to enjoy a healthy life for many more years. Life is just too short to waste days or weeks of it being sick. So, I’m OK with being weird.

October 28, 2022

By James Allen, MD

I am a Professor Emeritus of Internal Medicine at the Ohio State University and former Medical Director of Ohio State University East Hospital