1.1 Face covering as infection control tool
Framed as a medical narrative, a face covering can be considered as a
piece of personal protective equipment (what a health worker wears when
assisting an infectious patient) or as a means of source control to
prevent the spread of illness to others (something that a patient with
cystic fibrosis wears to prevent the spread of Pseudomonas
Aeruginosa when visiting an out-patients clinic) or a combination (the
face covering that a dentist uses during dental work). Infection control
guidelines are usually developed top-down, for example, guidelines
formulated on a global level are adapted nationally, then promoted at
local level through facility-based infection control committees.
Manufacturing is subject to stringent quality standards (for example in
the United States through the National Institute for Occupational Safety
and Health in the United States) and procurement is organised on a
national level. In countries whose response to COVID-19 was to promote
medical masks as face covering for use by the public, production and
distribution was coordinated on a national level. For example, South
Korea introduced price limits on medical masks, rationed and
nationalised distribution through country-wide pharmacy networks,
agricultural co-operatives and post offices in rural areas and organised
purchase dates based on date of birth.6
When viewing a face covering as medical equipment, filtration efficacy
(number of layers and type of material) and optimal fit are key decision
criteria. Health workers are trained in standardised infection control
techniques, often using simulations with a UV lamp that show how lapses
lead to self-contamination or infection risk to patients.
Metaphorically, this is akin to placing a protective armour to fight an
invisible threat. Donning (putting on) and doffing (taking off)
technique when using a face covering is important.
The contribution of infection control as a discipline in creating safe
healthcare facilities for patients and health workers have been
significant and impactful. However, transposing this medical narrative
for public face covering regulations has limitations.7Most randomised controlled trials of the efficacy of face covering have
been done in healthcare facilities, where the primary goal of using a
face covering is to protect the wearer from infection. Randomised
controlled trials on the efficacy of face coverings as source control
(i.e. to protect others) are sparse.7 Indeed, WHO
interim guidance produced in April 2020 advised that there was “no
evidence to suggest” that the intervention would be
effective.8 Other authors have argued that for
widespread public health interventions, randomized control trial
evidence is seldom available or ethical to obtain.7Furthermore, aiming for standardisation in making, using and cleaning of
a face covering at population level is challenging when people in
different contexts have access to vastly different resources. In such
circumstances, making the task of putting on and taking off a face
covering feel complicated and risky also makes it more difficult to
implement and may add little benefit when a face covering is used as
source control rather than personal protective equipment. Applying the
medical narrative to the cloth around the face, and sociocultural
narrative to the cloth around the rest of the body, makes for a
mismatched analytic approach to public apparel.